Las Vegas — Even at just 48 years old, Eleanor Mrozek represents the epitome of this country’s need for a healthcare system predicated on value. Diagnosed with HIV before her 25th birthday, she has long carried the emotional and physical impact of the disease that only the “lifers” can relate to. Experiencing just about every comorbid malady the virus can cause, from pneumonia, thrush, and diabetes to pancreatitis, cirrhosis, kidney failure, and hepatitis C, Mrozek has been in and out of hospitals, physician’s offices, dialysis centers, infectious disease specialists, and, more commonly today, wound clinics for most of her adult years.
At Kindred Hospital Las Vegas – Sahara, where Today’s Wound Clinic (TWC) recently spent time speaking with patients, providers, and administrators, Mrozek jokingly refers to herself as the facility’s “most tenured patient.” It’s been eight years since the diabetic foot ulcers (DFUs) began taking over her feet and visits for outpatient wound care became part of her regular appointment routine. All kidding aside, however, she might just become one of the hospital’s most “famous” patients as it transitions into its role as a member of an accountable care organization (ACO).
As the newly appointed post-acute care network within the Silver State ACO, a collaborative effort of hospitals, physician groups, and individual doctors serving Southern Nevada, Kindred serves as the post-acute resource for the ACO’s Medicare patients who will be tracked for all healthcare services and outcomes throughout the ACO’s care continuum in an attempt to avoid rehospitalizations and improve quality outcomes. Specifically, the outpatient wound clinic at Kindred Hospital – Sahara is positioned to play particular importance due to its role within the facility, a long-term acute care (LTAC) hospital that has become known in the region for its expertise in providing both inpatient and outpatient wound care, among other specialty areas, according to Estrella Sutton, BSN, RN, chief clinical officer, chief nursing officer.
“The formation of this ACO is a great opportunity that will give us a chance to make an impact on these patients by following them through all levels of care, from the acute side to post-acute, including home or hospice, if that’s what’s needed,” said Sutton, who also serves in her capacity at Kindred’s two additional Las Vegas-based hospitals – Flamingo and Rose de Lima.
Further contributing to the presence of the Sahara clinic as it relates to the ACO is that it’s the only hospital-based outpatient wound care department within Kindred’s Las Vegas network. If that weren’t prestigious enough, the Sahara facility’s participation within Silver State also represents the first of any Kindred hospital to partner with an ACO.
“So we’re actually utilizing this as an opportunity to see how we may be able to take this model to the other integrative markets that we have throughout the company,” said Doug McCoy, chief executive officer.
Tracking & Transitioning
Through the utilization of a “care transitions” model of tracking patients within its own infrastructure, Kindred administrators believe they have an appropriate protocol already established that will assist the ACO in tracking Medicare patients throughout the care continuum, regardless of a patient’s direct affiliation with the ACO. Reported data within the ACO participants will include each patient’s diagnosis within each facility in which they’re cared for as well as discharge dates, next level of care required, and records of any subsequent hospital stays that may be needed. Having officially joined the ACO in May 2014, Kindred is expecting to report its progress to ACO officials within one year’s time. As that deadline nears, those who spoke with TWC remain confident that the system will prove to be effective moving forward.
“We’re building a care transitions team in place that, once any ACO patient has been identified in any level of care in any setting, initially mobilizes the care transition team and all necessary staff to ensure everyone is getting to the proper levels of care correctly and consistently while monitoring these patients throughout their episodes of care,” said Gay Echiverri, BSN, RN, wound care coordinator at the Sahara facility.
By integrating the care transition concept into the ACO, all patients who are cared for at a network provider hospital will be flagged an ACO patient and be offered the Kindred post-acute care network if additional care is required. “So, if they come in with a severe wound, we’ll follow them into the outpatient clinic here and [eventually] into the home setting,” Sutton explained. “And we’ll have a care transitions manager assigned who will follow each patient through all levels of an episode of care within the care network. However, if the patient wants to use another provider we’ll honor that as well, [whether or not they’re a beneficiary of the ACO].”
Although at the time of TWC’s visit it was still too early to have any definitive records related to the number of ACO patients cared for at Kindred, officials expect the wound care population to mimic the facility’s highly trafficked inpatient and outpatient wound settings. As with any ACO, patients must also be under the primary care of an ACO physician, of which Silver State had 150 at the time of TWC’s visit, in order to be tracked through the ACO system.
“There’s never less than 80 percent of the patient population in our transitional care hospital who don’t also have a chronic wound that may require discharge into the outpatient clinic,” Echiverri said.
As Sutton and McCoy explain, part of Kindred’s responsibilities assumed with its ACO role is devising system processes for post-acute care.
“When the ACO started there wasn’t a network tied to [post-acute care],” McCoy added. “That’s a newer evolution of this ACO. Where wound care will fit — we’re still fine-tuning the details, but this clinic is designed to be the wound care hub for the post-acute resource network within this ACO. We look at it as a great opportunity. The partnerships that we’ve developed with our physician groups and the different level of services we have in the continuum will elevate our chances of being successful because we have all our stakeholders well integrated versus trying to get different organizations to be stakeholders. We’re actually able to provide all that post short-term acute care activity through our own group.”
One Patient’s Course
Now nearly 10 years removed from the formation of her first DFUs, a pair of sores near her right ankle, Mrozek said it’s been about six years since she can remember having full feeling in either foot. Her feet have become so ravaged by ulcers that she no longer has the ability to walk more than the few paces required to get from her wheelchair, which she’s basically confined to, into the bathroom or her bed. Living with osteomyelitis, severe edema, and chronic venous insufficiency, Mrozek said she’s had as many as three wounds on either foot ever since that started forming, which has been credited as a consequence to developing pancreatitis and diabetes in 2008 as a result of many years on an HIV drug cocktail. Born and raised in Brooklyn, NY, where, as she puts it, “you’re always walking somewhere,” Mrozek said the inability to walk freely has been the most devastating consequence of her healthcare to date. “Where I’m from, you’ll walk to the train, to get a cup of coffee or a newspaper, to see a movie or a show — you walk everywhere,” she said. “It’s just hard for me to stay off my feet because I’m very independent.”
So independent, in fact, that she confidently refuses the notion of ever undergoing an amputation despite concerns from her providers that it may eventually become reality.
To best assure against this, Mrozek recently began to undergo hyperbaric treatments and to become more committed to being accountable for her self-care, a responsibility she had been lacking over years past.
“I’ve been through so much already,” she continued, acknowledging the emotional stress that accompanies the multiple diagnoses she’s had, which also include thyroid disease, kidney failure, and liver cirrhosis. “At this point, you could tell me I have cancer tomorrow and I would just check it off the list. And I’d rather die than to have anything amputated, so I needed to decide for myself that I was going to live and stay off my feet and control my sugar so that the hyperbarics would work because I knew it was my last hope.”
At the time of TWC’s visit to the clinic, Mrozek had progressed through roughly half of her anticipated 30 hyperbaric treatments, which she undergoes five times per week. With DFUs, osteomyelitis, and venous stasis currently affecting both feet, including a surgical wound to the left foot that had previously been healed but re-infected multiple times due to her slower rate of healing and reluctance to refrain from walking, Mrozek remains optimistic because she has seen real improvement — albeit gradually. She’s no longer on IV medications for infection, one encouraging sign she’s using as motivation.
“I saw my foot go from normal color, to purple, to black, to healing now,” she continued. I’m healing, but I keep getting reminded that I might need an amputation. Even if they took my legs off, I know I’d still have complications and wounds. But I have been staying off my feel because I really wasn’t healing before. I’ve been through casts and braces, and this is my last chance at a solution.”
Further aiding her chances for success has also been a better commitment to her diabetes care, which Mrozek said at one time she did not devote herself to much like she previously neglected her HIV treatment regimen. At the time that she arrived to the region from the East Coast nearly 17 years ago, a decision she said she made to be closer to family, Mrozek was essentially an untreated HIV patient.
“I had six T cells when I [first saw a doctor here], and my viral load was in the billions,” she explained. “But today I have 550 T cells and my viral load has been ‘undetectable.’”
She has many providers in her care network who’ve had their part in keeping her as healthy as possible despite her not being among the ACO, but she feels a certain need to especially credit Kindred and its wound clinic staff for the commitment to her health that she’s developed over the years.
“I used to skip a lot of doctor’s appointments because I never felt like they really cared about me, but here it is different,” she said. “They’ll try anything to make you comfortable and happy — anything to make your day better. Some other places, you go and you feel like you’re ‘just a number.’ It’s just surgery after surgery, cast after cast, and then one day they tell you, ‘We don’t know what to do anymore.’”
Value For All
The recent announcement that the US Department of Health and Human Services is fast-forwarding its already ambitious plans to usher in this country’s value-based healthcare financial plans and tie 30% of traditional payments to quality or value through alternative payment models such as ACOs before 2017 (with a goal of 50-90% of all payments to be “value based” by 2018) exemplifies such a need for outcomes to take more priority not just among ACO patients but for all across the care spectrum.
At Kindred, officials and staff believe this is already reality through the care transition process that has existed not just through the internal transitions from the inpatient to the outpatient side but through an established process that has been utilized among referred patients as well. Today, the ACO might just put on record the “credit” that they aren’t necessarily seeking beyond continuing to achieve patient satisfaction.
“Many of the patients we have here are success stories from the inpatient side who have already been discharged home and will now be followed from a care-transitions process through the ACO,” McCoy said. “With this clinic, we’re able to ensure that the timeliness of physician service is consistent, whereas if we sent these folks elsewhere, where they weren’t seen as inpatients first by the same providers, keeping that continuity of care would be challenging.”
“That to me is the financial gain for the building as well,” McCoy continued. “The actual reimbursement for services provided through the outpatient clinic is not significant. There’s not a huge margin for us. But again, to provide that as part of the ACO is a big plus. And it’s helping us on the inpatient side because as the patient’s experience in the outpatient setting is positive, if they need an inpatient stay you and your physician are already connected in that way.”
As a member of Desert West Surgery, a local physician group that attends to both inpatient and outpatient wound care at Kindred Hospital - Sahara, Elijah Johnson, MD, FACS, agrees that the effectiveness of the care transition protocol at Kindred predates the affiliation with the ACO, which he and his group are not affiliated with.
“I’m very impressed with the care that goes on here,” he said. “From admission and assessment to discharge the coordination of care here is very effective. They will have the results to prove it, too.”
Joe Darrah is managing editor of Today’s Wound Clinic.
Career Path Worth Taking
One nurse finds his way into wound care through a determined, albeit unlikely fashion.
Brian Olbrych, RN, wasn’t always certain of the capacity in which he wanted to work in healthcare. He only knew that, for as long as he can remember, he wanted to be involved with patients in a setting where he’d be able to help people heal and to see people healing as it happened.
Like many of us, these aspirations took some time to mature into an actual career path when after high school he remained undecided and put off furthering his education until he had a clearer vision for what best suited him.
A native of Houston who grew up in southwest Louisiana, Olbrych remained undecided two years following his high school graduation. Although he enrolled in nursing school soon after commencement, costs proved too high to see an appropriate education all the way through. After spending about two years working at a local grocery store, he decided to enroll in the US Navy on the advice of a military friend who suggested he speak with a recruiter about educational opportunities and the relatable experience he’d gain as someone interested in serving others.
“Growing up in Louisiana, I knew that I didn’t want to get dirty on oil rigs, that I wanted to be a doctor, or a nurse — someone in the medical field in some way,” said the now 40-year-old who recently earned his credentials as a registered nurse. “I always liked the idea of helping people get from an injured or sick phase into a healthy phase. I like that feeling where you help people get better by helping them understand what’s wrong and helping to educate their families. Being able to hear them say ‘thank you’ is very rewarding. I’ve always had this pathway as a goal. It just took me a little while to get here.”
Today, as a med/surg nurse his relationships with wound care patients occur on the inpatient side, a bit of a change of pace from his involvement in their treatments as the hospital’s hyperbarics program director, a post he held with Kindred for five years before earning his nursing education and a field of care he landed in following his military discharge. Prior to that he had served as a chamber operator, but the patient care aspect of the job continued to be a draw to him more so than the maintenance and equipment repair.
“When I left the Navy I was looking for a path in medical care,” Olbrych explained. “I soon got into scuba diving and decompression sickness, reading the literature and doing research. When I returned to the Sates, I went to school to become a dive-medic, learning to become a commercial diver and how to conduct chamber operations. The physiology of the hyperbaric treatment — what it does to the body and how it helps speed the recovery process of patients in conjunction with therapies — is what kept me in it for so long.”
Still, that urge to become more involved in direct patient care continued to be a part of him. He earned his nursing degree through an accelerated RN program at Kaplan College and is currently enrolled in an 18-month RN-to-BSN program, which he intends to use as a springboard to an eventual MSN degree. Ultimately he sees himself in the intensive-care unit, though he does plan to keep his hyperbarics certification active for the foreseeable future.
“I’ve always enjoyed the critical part of medicine,” he said. “It’s stayed with me all these years and that’s what I want to transition into. And I don’t want to procrastinate with that like I did out of high school.”
— Joe Darrah
A Patient’s Path to Adhering to Compliance
Robert Mierkey admits he wouldn’t be the productive patient he is today without the patience of his providers.
The difference between patient compliance and patient adherence, and the political correctness of both terms, has increasingly become debatable among healthcare professionals.
Adherence has been defined as the “active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result.”1,2 Compliance, meanwhile, is considered to be “the extent to which a person's behavior coincides with medical advice.”3 According to AM Delamater,3 the notion of “noncompliance” then is essentially reserved for those patients who disobey the advice of their healthcare providers, an action (or inaction) that’s attributed to personal qualities, such as forgetfulness, lack of will power or discipline, or low levels of education.
To many, a lack of appropriate patient education as shared by one’s provider is the most likely of culprits when patients are labeled as noncompliant, an offensive and shortsighted descriptor of someone, say those providers from this vantage point.
Regardless of one’s views on the distinction between the two, wound care patients remain a prominent source for this discussion due to the nature of the comorbid conditions they’re likely living with as well as the inherent need to provide self-care in order to achieve positive outcomes. Peeling the onion even further, when chronic wounds aren’t healing, or aren’t healing as quickly or as fully as they should be in the outpatient setting, the lines between judging nonadherence and noncompliance may be at their most grey since wound care clinicians are typically not going to be able to hands-on observe the patient’s contributions to healing away from the clinic.
That is, unless your patients are as honest as Robert Mierkey, a now reformed noncompliant patient who has been in and out of the Wound Care Clinic at Kindred Hospital Las Vegas – Sahara almost as many times as he has remaining appendages.
“I wasn’t taking care of myself by staying off my foot like I was told to do by my doctors and nurses, but now I know better.”
Looking back over the course of his care over the last several years during a recent visit to the clinic by Today’s Wound Clinic, Mierkey, 70, can also honestly say that he would not be the compliant patient that he is today had it not been for this clinic and its staff.
Diagnosed with type 1 diabetes at the age of 40, Mierkey knows the value of following protocol. A longtime police officer in his native Freemont, CA, retired and moved to Vegas in 2004 with his family as a relatively healthy individual. At least, that’s how he saw himself then even though he had previously lost multiple toes to amputation (today he’s up to three, including his big toe) on his right foot. Having gone about 10 years from the time of his diagnosis before experiencing severe diabetes-related complications, Mierkey in 1994 began to show signs of his disease in the form of chronic wounds while on vacation with his wife in Hawaii.
“We were walking on the beach, and I stepped on a seashell, slicing my foot,” he related. “I saw a doctor there who cleaned it and wrapped it up and told me to see my doctor when I returned home [about one week later]. I was told there was no infection, and that was it.”
By the time he got home, however, an infection had set in — to the bone — and amputation was necessary.
He would miss a few months of work, but for the most part did not endure what he considered to be any major limitations in his daily life. Then a bit of a “freak” accident occurred four years ago, again while Mierkey was vacationing with his wife, this time in the Philippines.
“We were at a resort, and I was in the pool, and when I went to get out I used the railway instead of the steps,” he explained. “And I slipped, hitting my heel on the bottom of the pool.”
His lack of balance also partly the blame, the fall resulted in what Mierkey described as a blood blister to the right heel, which he did not have treated but informed his doctor of upon returning home just a few days later.
“But it wasn’t anything I described as an ‘emergency,’ he said. “When I saw him I was told ‘we have to do something right away.’ The blister had broken open when I got home and was quite deep.”
Treated at Kindred, the wound did heal to the point that he was discharged from outpatient care. Mierkey was instructed to avoid ambulating as much as possible to avoid further complications. Admittedly, he didn’t really comply with that at all.
“I was stubborn, and didn’t take care of myself by staying off my foot,” he said. “I was healed and thought ‘I’m ready to go.’ And it opened up again and got infected.”
That was last winter. He saw a podiatrist, who performed a skin graft and, like his physician, referred him to Kindred for treatment of the infection, which required an inpatient stay, and hyperbarics.
Today, the wound is barely noticeable; but Mierkey has grown cautious enough that he checks it twice per day. And while he’s fairly certain he could get around without the wheelchair, cane, or orthotic shoes he now owns, he’s confident he won’t be attempting that. “I don’t enjoy being in the wheelchair, and I don’t enjoy sitting around at home; but I want this to heal. I’m not going to make the same mistakes again. From the information and education I’ve received here I know that if I’m going to be able to really walk again I need to stay off my feet. The staff here can’t monitor me 24/7, but they’ve helped me see this is the way it has to be and have challenged me to take part in my healing. I don’t want to be someplace where they’re not going to talk to me about my condition. I don’t need to worry about that here.”
— Joe Darrah
1. Kurtz SMS: Adherence to diabetes regimens: empirical status and clinical applications. Diabetes Educ.16:50-56, 1990.
2. Kravitz RL, Hays, RD, Sherbourne CD, DiMatteo MR, Rogers WH, Ordway L, Green-field S: Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 153:1869-1878;1993.
3. Delamater AM. Improving patient adherence. Clinical Diabetes. 24:2;71-77.