As a new year begins, several experts provide their insights into the biggest challenges facing the wound clinic, how clinics have adapted since COVID-19, and what gives them optimism in 2021.
What are the biggest challenges going into 2021?
Caroline E. Fife, MD, FAAFP, CWS, FUHM, cites challenges with handling patient volume, noting her facility is struggling to see the number of patients needed to maintain staffing levels.
“Patients are still afraid to come,” says Dr. Fife. “We will likely have a difficult winter with regard to COVID and it is possible that there could be partial lockdowns.”
Those in long term care will agree that the biggest challenge continues to be COVID-19, notes Jeanine Maguire, PT, MS, CWS. She says among the challenges with the pandemic are keeping residents, patients and staff healthy; performing the point of care testing; and now, vaccines. Ms. Maguire agrees that occupancy is still suffering as people opt to go home, even when they really need care, due to fears of COVID.
Telemedicine will continue to be a primary mode of conducting wound care visits, but Traci A. Kimball, MD, CWSP, notes the technical challenges with devices and bandwidth raise issues and may lead to delays in care.
“Patients many times don't have a smart device or computer to conduct the visit from their end; and if they do own a device the connection bandwidth is slow such that wound images come across as poor quality,” notes Dr. Kimball.
Ms. Maguire also notes challenges with skin health and wound management during the pandemic. Before COVID-19, she says 60,000 people died every year from pressure injuries, and adds that the older population that lives in long term care has multiple comorbid conditions, medications, cognitive impairments, and mobility issues. All of these give this population a higher prevalence of a variety of chronic ulcers from arterial wounds, diabetic neuropathic, and venous ulcers, notes Ms. Maguire.
“These issues are complex and multifactorial, and did not go away because COVID became a top priority,” says Ms. Maguire. “In fact, active COVID infection may have exacerbated chronic wound decline and/or contributed to biofilm states and recalcitrance. Lastly, COVID itself may even have manifested as a skin impairment itself.”
As we emerge into a post-COVID world, Ms. Maguire says a major challenge will be evaluating the overall impact of COVID and understanding the direct impact on the long-term care population. She poses several pertinent questions: What are the unintended consequences of the needed COVID responses for infection control? What is the impact on mental health of residents and staff? What about the impact on mobility and weight loss? What will be the residual impact on communal living in general, and ultimately, what are the effects to skin health and wound management?
In 2021, wound clinics will face the challenge of getting their practice revenue back to 2019 levels, according to Eric Lullove, DPM, CWSP, FACCWS, FAPWCA. He notes there will be challenges related to seeing where patients have been hurt the most financially and the struggle for possible loss of insurance coverage due to loss of employment.
As Dr. Fife says, physicians are having to figure out the new evaluation and management (E/M) coding. Although the Centers for Medicare and Medicaid Services (CMS) may believe it has made things better, she notes the change requires a lot of resources, and she says and resources are very limited right now.
For Harriet Jones, MD, FACP, the challenges include remaining flexible and not giving in to COVID-19 fatigue. “I imagine there will be more ups and downs still,” she says. Similarly, Dr. Lullove says it will be challenging to get back to the new "normal" and face continued pandemic issues for the first 6 months of 2021.
“This work was hard before COVID. I am humbled by every caregiver and every person that continues to serve long-term care during these difficult times,” notes Ms. Maguire.
“I mean everyone, whether you are directly providing care or you make sure we have what we need to do so: housekeepers, dietary aides, administrators, therapists, social services—everyone.”
Dr. Fife notes challenges with staff morale due to COVID-19. “Everyone has been affected somehow. Everyone is weary and many are depressed.”
Another challenge Dr. Fife acknowledges is a lack of “bandwidth” to handle the usual non-COVID related workload. “We live under the tyranny of the urgent and don’t get to spend time on important things we would normally focus on like quality initiatives, formulary changes, patient satisfaction,” she stresses.
“It has been an all-hands-on deck to battle COVID and to continue to support and care for vulnerable individuals and their families,” says Dr. Maguire.
What are the most effective strategies for meeting those challenges?
Meeting challenges, for Dr. Jones, means staying healthy and staying in touch with local health departments' guidelines. She also advises practicing humility in one’s dealings with all health care professionals one works with and answers to. Similarly, Dr. Fife advises physicians to spend a bit more time focusing on encouraging each other.
Dr. Lullove cites the importance of continuing to interact with local and state health departments to get as much information as possible. He notes clinicians should find unmet ways to increase revenue and to help patients deal with COVID-related issues with wound healing. Finally, it is important to continue multispecialty networking and management of patients, says Dr. Lullove.
Since Dr. Fife’s hospital system won’t advertise wound management services, she says the hospital has no way to improve its volume except word of mouth and waiting for patients to feel comfortable returning to the doctor.
Dr. Kimball advocates sending mobile field teams of nursing professionals in full personal protective equipment (PPE) to patients’ bedsides to facilitate telemedicine visits for patients with wounds. As she notes, using mobile nursing units with a central mission control monitored by a wound specialist “is a nice marriage to provide comprehensive wound management services during a pandemic.”
As for E/M code changes, Dr. Fife notes they are time-consuming and complicated. She says physicians have to adjust with or without the help of all the members of the team who are needed to implement that change.
As for the “usual work” that is not getting done, “all we can do is identify the most pressing concerns and try to tackle those,” says Dr. Fife.
Dr. Kimball calls for the expansion of tax law to allow smart devices and internet to be paid for with flexible spending account (FSA) and health savings account (HSA) funds. She says insurance carriers could provide telemedicine seminars to educate patients on how to conduct a telemedicine visit and provide info on what the minimum technical specs should be to have a high-fidelity wound care visit. She also suggests the expansion of in-home care resources for wound care including smart devices provided by the home health agency.
The most effective strategy Ms. Maguire learned was the concept of “the one thing,” the idea that COVID-19 forced people into action around all-things-COVID in every line of business. “I have never witnessed such a team approach willing to do whatever it took for our residents’ health and our staff,” she notes. “It was amazing.”
For Ms. Maguire, that team approach reinforced two ideas when it comes to a strategy for success. First, it takes a team working together with the same vision. Second, for a dramatic change to be successful, it takes a systems-thinking approach where every line of business is engaged for one ultimate goal. What that means for a wound specialist? Ms. Maguire says she needs to approach skin health and wound care from a systems-thinking team approach if she’d like to be effective in changing population outcomes.
Did you learn anything/make any innovations from facing COVID-19 that could help in 2021?
In 2020, Dr. Lullove converted his facility to a full testing facility in light of loss of patient revenue and practice volume. He offered increased vascular testing and biopsy technique procedural medicine, and also offered increased usage of fluorescence imaging to improve patient outcomes.
Virtual meetings, virtual wound education, and virtual rounds can be a way to effectively support any wound team at any location at any time, asserts Ms. Maguire. When it comes to the complexity of wounds in long term care, she notes COVID-19 has shifted remote support for wounds to the forefront, saying this allows practitioners the opportunity to have a specialist at the bedside when the time is right for the resident and the center team.
“This has potential to improve wound outcomes for those in long term care dramatically as it sets the stage for true person-centered care, bringing the team together in a more dignified manner for the resident, while addressing 'what matters most' to that resident,” says Ms. Maguire.
Although she notes the virtual approach cannot and should not always replace the in-person visit for certain complex assessments and procedures, Ms. Maguire says practitioners can use a virtual approach to triage-forward care in order to determine if/when those services are needed. She hopes this approach will continue and become a standard for wound management in long-term care.
Noting the rise in telemedicine due to the pandemic, Dr. Fife says while this is not a bad thing, it’s not a long-term solution for wound care.
Dr. Kimball’s facility conducted educational events to teach their wound care treatment nurses about wound hygiene and the importance to "clean it like you mean it." Dr. Fife agrees, noting more attention to hand hygiene, as many emphasized during the pandemic, is always beneficial.
Dr. Kimball also wrote policy to support nursing to function at the top of their scope and allow wound care treatment nurses to provide chemical cauterization and chemical desiccation of wound biofilm.
What gives you optimism for 2021?
In terms of COVID-19, Dr. Jones says the vaccinations are going to be “immensely helpful” in terms of letting people get close to back to normal. Dr. Lullove agrees, saying if vaccines prove effective, life can return to “normal.” He feels health care will have a preferential position at the forefront of concerns in 2021.
Dr. Fife agrees about the utility of a COVID vaccine, saying it will help her practice more effectively and boost morale.
“I can’t effectively practice wearing a mask all the time. Patients can’t understand what I am saying, and I need to be able to see their face and facial expressions to fully evaluate them,” says Dr. Fife. “I will keep struggling with my own mood problems until I don’t have to wear a mask.”
Dr. Kimball agrees, saying the development and widespread implementation of a vaccine would allow for increased face-to-face visits. A vaccine, she notes, would also reinstate the weekly frequency of sharp wound debridement for wound bed preparation and the ambulatory application of tissue substitutes for limb salvage.
Ms. Maguire acknowledges nursing homes were devastated by COVID-19, whether it was the disease itself or the processes that were required to prevent its spread. As she notes, history shows that every time the nursing home industry has improved in regulation and funding, it was only after significant issues and societal awareness.
“I feel a global pandemic may have been that needed shift to raise awareness of the societal need for long-term care and the need for increased funding to change the structures, the processes, upgrade technologies, and revise the care delivery in long-term care in order to create a space where people are proud to live and work,” says Ms. Maguire.
Finally, Dr. Lullove feels optimistic because a Democratic White House “gives optimism as health care and education will become central issues next year.”
Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.
Harriet Jones, MD, FACP, practices at the Internal Medicine Group of St. Dominic’s Hospital in Jackson, MS.
Traci A. Kimball is a Certified Wound Specialist Physician with InnovAge Greater Colorado PACE-Denver Metro.
Eric Lullove, DPM, CWSP, FACCWS, FAPWCA, is the Chief Medical Officer of the West Boca Center for Wound Healing in Coconut Creek, FL.
Jeanine Maguire, PT, MS, CWS, is the Vice President for Skin Integrity & Wound Management at Genesis HealthCare in Kennett Square, PA.