San Antonio — This country’s current healthcare transition from volume-based care to a system predicated on value and quality can be just as complicated to understand for the patients who stand to benefit from its changes as it has been daunting for the providers who are required to make the adjustments.
At Northeast Baptist Hospital in San Antonio, the Wound Healing Center and its staff of multidisciplinary clinicians have taken a proactive approach to best assuring continued quality of care and services by bridging any perceived gap that could arise as a consequence to such a systemic overhaul before any such gap has even had a chance to form.
Through the utilization of a case management system and a patient navigation protocol that literally guides and educates wound care patients along each step of the healing process from admissions to discharge — across the entire continuum of care — administrators and providers at Baptist believe they are successfully educating and empowering their patients, as well their staff members, related to the modifications to care delivery that are occurring and will continue to occur as today’s healthcare shift progresses. For patients, this means being given more time with the wound physicians, surgeons, nurses, and therapists at the point of care. For staff members, it means more opportunity to have the appropriate hands-on interaction needed to provide the level of clinical quality expected of them that’s inherent with the new-look healthcare model, as well as guidance in making adjustments to existing protocol and relevant training to achieve goals set on quality.
Today’s Wound Clinic recently visited the outpatient wound clinic at Baptist to speak with providers and patients about the impact that the facility’s approach to care has had on everyone involved.
“I think we’re all understanding the way that things are headed with this transition, and Baptist, as a system, wants to make sure we’re all providing cost-effective, high-quality care in all of our programs,” said Jayesh Shah, MD, medical director of the Northeast Hospital wound center. “And everything we’re doing here and throughout our health system makes sense when you consider the bigger picture. We all have to work together and learn together to get where we’re going and to make sure we’re getting the best outcomes for our patients at the least cost to our hospital and healthcare system.”
Since opening its doors in 2010, the Baptist Northeast wound clinic has always been in a position to perform high-quality care designed to offer patients the individual attention and care planning necessary to treat the chronic wound population, according to E. Patricia Rios, MSN, RN, CHRNC, program director. “You don’t typically get referred to a wound center if you’re otherwise healthy and would have a wound heal in a normal amount of time. The big thing for us has become maintaining the quality of care we’ve already provide here,” she said.
This has meant taking an objective look at policies and procedures already proven effective that have long been in place and making slight modifications. The results have been rather significant, however. As an example, Rios and Shah discussed an adjustment to the physicians’ methods of communication while with patients in the examination room, where the physicians now document each case while remaining with the patient following their assessment. Both Rios and Shah said the practice has been received well by their patients because they now have more time to ask questions and — perhaps more importantly — get answers while their doctor is in the room. Chalk one up to the benefits of advanced technology, which has evidently reached the point that patients do not feel neglected if they’re having a discussion with their physicians while he accesses their electronic health record (EHR) if it means they get more time in the room with them, conceivable while they themselves fiddle with their phones.
“Instead of patients having to relay their questions to their doctors through their nurse, we’re staying in the room with them to answer everything they have questions about,” said Shah. “We do try to make it a point to be facing the patient when talking to them, even if we’re in front of the EHR, because they do want that interaction as much as possible, and we’re finding that when we leave the room we know that we’ve done everything for that patient as their physician. Everything’s been ordered and e-prescribed, they have all the supplies that they will need, and everything is situated with home health. As physicians, we know that we’re not done with what we have to do for our patients until the last one leaves for the day and the documentation is completed with them.”
In addition to ensuring that the physicians and patients have had ample time to communicate, the practice of documenting together has had additional benefits, according to Rios.
“In my opinion, the sooner you conduct the documentation to the time you provided the service, the more complete the documentation is and the amount of time it takes to be done is reduced compared to trying to do it all at the end of the day,” she said. “It also allows the physicians to close the circle with the patients and the nurses because when they walk out of the room the nurses are already there to provide the prescribed treatments and the patients know what they need to do (regarding their self-care). We’re able to maximize the amount of time that they have face-to-face with the physician and the nurse, so that they can have their questions answered, know that their needs were addressed, and actually be able to remember the experience.”
In their case management role, the clinic’s registered nurses are assigned patients for whom they care for throughout the duration of their treatments and perform duties such as intake, risk assessment, dressing removal and application at each visit, and coordinate any services needed at home and/or with durable medical equipment suppliers. The nursing staff also includes licensed vocational nurses who work with patients on their return visits to assist with the intake process, vital signs, dressing removal and replacement, and education.
“The nurses are responsible for the clinical flow of the center,” said Susanne Gregory, RN, clinic nurse manager. “Every patient leaves here on their first visit with a plan of care. They know what the next steps are and what they need to do. And we screen them on a weekly basis for how well they’re doing with that plan. If they’re providing self-care at home we’re doing that ongoing teaching or arrange for home health if they’re unable to care for themselves.”
It’s just one component of the clinic’s “navigation” system that has been designed to provide patients with a structure to their care plans based on individualized interaction with their physicians and nurses.
With a multidisciplinary medical staff that includes vascular surgeons, plastic surgeons, podiatrists, and infectious disease physicians, the evolvement of the clinic’s patient navigation philosophy is born out of a shared belief among staff that each patient should be assisted by a dedicated physician and nurse throughout each stage of the healing process as the patient moves along the spectrum of care pursuant to their wound and comorbidities.
“From the time they arrive for their first scheduled appointment and are registered at the front desk, we want our patients to know they have enough time with the physician and the case manager who’s coordinating their care,” Rios said. “The patient is greeted by the intake nurse who explains an overview of the entire wound healing process — the weekly visits, the debridements, the dressings — so that there’s no surprises. They’re also discussing wound history and nutrition, as well as screening for falls risk and abuse or neglect — anything that could interfere with a wound healing. The case manager and the physician then meet with the patient, and that’s where the real care coordination occurs and the decisions on how to move forward with the care plan are made.”
With each particular specialist the patient is required to see, the case manager fosters conversation related to why the wound is present, what potentially hasn’t worked up until that point, and how to bridge the next step in care planning.
“So, when we say ‘patient navigation,’ we’re saying that the case managers are ensuring that every order given by any of the physicians is explained to them by that physician, before they are carried out by the nurse, as well as meeting any additional needs,” Rios said. They’re the ‘hub’ of that patients care.”
Although each case manager will speak individually with the physician after each patient visit, as a group the nurses and physicians are also gathering frequently to ensure all staff members are fully informed on all patients.
“With pay moving to performance, we already meet weekly about providing appropriate care and achieving patient satisfaction and best outcomes,” Rios said.
Shah said the meetings not only help to keep everyone current on the condition of all patients being treated by reporting to one another, they foster the continued focus on quality measures when it comes to reporting to the Centers for Medicare & Medicaid Services’ Physician Quality Reporting System.
“There’s always room for improvement no matter how great your healing rates are,” he continued. “There are always quality issues you can take on and work on to improve upon to produce cost-effective quality care. It’s hard for any clinician to say you can heal a complex wound ‘quickly.’ But as long as our patients are getting all the right treatment that’s needed when they’re here, then we’re providing quality care. Clinically, I think what sets us apart is the way our multidisciplinary team works together. Our comprehensive approach has allowed us to achieve and maintain our best outcomes.”
Patient Profile: Leonard Marroquin
San Antonio — The weekly photographs had become too difficult for Leonard Marroquin to look at. Each time he’d visit the Wound Healing Center at Northeast Baptist Hospital, San Antonio, for treatment of the diabetic foot ulcer (DFU) under the big toe of his left foot, his physician and nurses would share with him photos of his healing wound and discuss with him his continuing care plan. But after about one month had passed the 42-year-old San Antonio native had asked that he no longer be shown the images. Though his clinicians had assured him the DFU was already making real improvement, Marroquin said he was not seeing it for himself — that the closure occurring was not evident from the images, even if the measurements said otherwise.
“The mind sees what it wants sometimes,” Marroquin said during a recent visit to the hospital by Today’s Wound Clinic (TWC). “And it’s tough to see that progress with the naked eye when you’re looking at it every day. I was feeling stagnant. I wasn’t seeing progress.”
For Marroquin, who injured his toe in late winter when he stepped on a screw while walking through a warehouse — his full-time job as a repairman for a local school district places him in such a setting frequently — the anxiety of what he perceived to be slow healing had manifested into an amount of stress that raised his blood pressure to the point that there was general concern that the true healing could have been negatively impacted. So, he decided to think less about the wound and more about the things he would need to continue to do — such as eating healthily and exercising to the extent that he safely could — to help his providers continue forward with wound closure.
“I’ve been doing a good job of managing my diabetes overall, but stress can affect things as well, and having this wound and being in the hospital just creates more stress for me,” he said. “So I’ve been just trying to take care of myself and get back into the rhythm of life.”
Having just completed his last of 40 hyperbaric treatment sessions at the time of the TWC clinic visit, Marroquin’s most recent dimensions for a wound that measured 3.0 cm x 2.5 cm with a depth of 0.9 cm when he presented (following an initial debridement) to Jayesh Shah, MD, medical director of the Northeast Hospital wound center, came in at 1.1 cm x 1.2 cm x 0.3.
“I’ve started to realize that there’s an improvement,” he said. “You really notice the big progress when you’re looking at it every day. I know now that it is getting better.”
One who weighed almost 350 pounds when he was diagnosed with type 2 diabetes about 10 years ago at the age of 30, Marroquin, who is down to 230 pounds and striving to weigh in at 200, has experience in making noticeable health improvements. At one time requiring daily insulin for his diabetes, he’s currently only taking two oral antibiotics due to recurrent infection in the wound thanks to his commitment to be more healthy.
“At one point I was drinking at least three sodas per day,” he said. “Now I’m drinking more water and unsweetened tea. I have cut back on the greasy foods and eat more baked fish and chicken. And the more I started to walk and exercise the more the weight gradually came down.”
A natural outdoorsman who is used to spending ample family time at the region’s state parks, such as Guadalupe River State Park, Marroquin has been able to ambulate and travel more to his liking since utilizing a scooter that he was able to obtain after the recent removal of his wound vac. Now permitted to drive as well, he looks forward to returning to work in the next few weeks and being relived of such stressors as maintaining medical appointments and financial obligations that are inherent when working full time is abruptly not possible.
“My faith and my family have helped me, and I’ve spent a lot of time here in the wound clinic with people I now consider family,” he said.
Physicians & Staff at Baptist Wound Clinic Preparing for ICD-10
The implementation deadline for ICD-10 coding conversion is now less than a month away. Once rumored to be delayed again, the conversion is all but guaranteed to take effect Oct. 1. Organizations such as the American Medical Association and the Centers for Medicare & Medicaid Services have offered tools and guidance for complying with the transition that will allow for flexibility in the claims-auditing and quality-reporting processes in response to requests from providers as the medical community gains experience using the new code set. While general concern exists that all healthcare providers and program mangers involved in coding and documenting will experience a certain degree of difficulty, particularly as it relates to achieving the appropriate level of reimbursement once the conversion occurs, staff members and physicians in the Wound Healing Center at Northeast Baptist Hospital, San Antonio, will be as prepared as possible for not just meeting the deadline but for making the transition as seamless as can be expected thanks to a training program that has now been ongoing for nearly one year.
Through the hospital’s management company Healogics, Jacksonville, FL, the wound care staff participates in weekly webinars hosted by the company’s regional reimbursement experts. Questions are fielded at the end of each session and the presentations are archived online to be accessed online.
“We’re preparing,” said E. Patricia Rios, MSN, RN, CHRN-C, program director. “We believe these implementation webinars for our physicians, nurses, and coders, will make a big difference for Baptist centers because we will all have had several months in order to prepare.”
The webinars dovetail with the facility’s general training programs and protocols, which include regular inservices whenever new products are introduced so that staff members can accurately educate patients and caregivers as well as annual competencies for all staff members, and additional sessions for new hires, that include module of study instruction followed by written tests and hands-on skill demonstration.
“We’re not just teaching staff how to do procedures, we’re teaching them why they’re providing these needed services as well on an ongoing basis,” Rios continued. “There’s not one cookie-cutter product in wound care that you can take off the shelf that’s going to help everybody. So when we add something, it’s more about keeping our heal rates consistent, making sure we are adding value.
Additionally, the clinic’s electronic health record includes a platform that features a cross-block from ICD-9 codes to those that will be used in ICD-10.
“It’s not part of the billing yet, but we’ve been training our physicians on what they will need to do differently,” Rios said.