Philadelphia, PA – The City of Brotherly Love is no stranger to world-class medical institutions. The regional population of 6 million people have numerous choices when it comes to seeking healthcare services. However, when it comes to those who require care of chronic wounds, the options are not as abundant. As wound care clinicians well know, patients benefit from access to community-based facilities for specialized wound care, especially in a city known for its many neighborhoods and distinct local characteristics and personalities. For residents of Roxborough, an area in the northwest section of the city founded more than three centuries ago,1 the Comprehensive Wound Healing Center at Roxborough Memorial Hospital bridges that gap between local and quality care.
“It’s very important for patients to have access to wound care services in their community hospital because of travel,” said Marie Marvel, RN, BS, WCC, director of wound care at the Roxborough clinic. “A lot of [patients] have difficultly ambulating, difficultly with transportation, and just difficultly with fitting it into their schedules. Hyperbaric oxygen therapy is a daily treatment, so for someone to fit that in a couple hours each day and carve it out into their schedule five days a week is significant.” Along with Catherine E. Cahill, DO, physician medical director, and a team of nurses, Marvel helps care for wound care patients who live in the neighborhood known for its hilly terrain and high elevation along the Schuylkill River, as well as those living in parts of eastern Montgomery County.
“I think the distinction between a community hospital versus a tertiary care center is important,” said Cahill. “Certainly, in Philadelphia we see several tertiary care centers that serve not only locally but nationally and, in some cases, globally, whereas our community hospital serves the local areas around us. That’s something we’re really proud of, because we’re able to offer top-notch care to our local community and that our patients don’t have to travel to get that.”
When the clinic was first conceived in the late 1990s, the driving force was need in the region. Providers had no choice but to handle wound care within the walls of their own practices, but patient outcomes were not as successful and required specialty equipment, supplies, and staff. Roxborough Memorial Hospital’s wound clinic evolved to fulfill this need, starting with a small patient caseload. As area providers saw positive patient outcomes, the caseload continued to grow. And, with a close-knit community like the northwest section of Philadelphia, word of mouth helped spread the center’s reputation as the go-to place for help with complex wounds.
The Comprehensive Wound Healing Center officially opened its doors in 1998 as one of the first small, community hospital settings to offer a hyperbaric oxygen and wound care specialty clinic. “I remember for many years after people would question, ‘Wow, Roxborough has hyperbarics?’” said Marvel, who helped expand the center when she joined the staff in 2000. “It was quite surprising and cutting-edge, and we were often asked to move ahead and assist other hospitals that were opening wound care centers in years following.”
A Changing Neighborhood
The clinic’s location is central to a section of Philadelphia that flourished during the industrial boom of the early 1900s. On a weekly basis, the facility sees anywhere between 30 and 60 patients who come from nearby rowhomes in neighborhoods built more than 100 years ago to provide housing for factory workers. Patient demographics have started to shift with the neighborhood’s growing population. “Twenty, thirty years ago, it was a mostly middle class, blue-collar crowd,” explained Cahill. “Now, you have the dawn of Manayunk, which is a younger population. So, we see people under the age of 30 with traumatic wounds, burns, lacerations, et cetera, anywhere up to octogenarians, and then some with your classic wound care needs — be it venous stasis ulcers or arterial ulcers, and obviously diabetic foot wounds. Our patient population is a reflection of this ever-changing area, from the millennials in Manayunk to the patients who are ever loyal to the Roxborough area.”
When asked about patients who stick out among their weekly cohorts, Cahill could quickly recall one particular patient. “I met this woman when I started here at the center,” Cahill said. “She’s lovely, but noncompliant, as some wound care patients tend to be. I got to know her very well since she came in weekly, and immediately she kind of became part of our wound care family. She had severe venous stasis ulcers, and I encouraged her to wear compression stockings, to take her diuretic, to offload, and to wear her pumps.”
“Fast forward two years, dealing with noncompliance and other issues, and a hospital stay brought a lot of these issues to light,” Cahill continued. “It was sort of a wakeup call for her. From the time she was admitted to the hospital about six months ago [at the time of interviews conducted by Today’s Wound Clinic] to now, her wounds are healed. While we’ve known her for the last two-and-a-half years, it’s really been in these last six months that she’s realized that these are the things we’ve been recommending to her this whole time, but now she’s finally doing them, and her wounds have healed. It was a challenging case, because of patient background, financial issues, and everything else we have a tendency to deal with, but it was satisfying because now we see her wounds are healed. It’s wonderful.”
Another patient living with a diabetic foot ulcer (DFU) made for interesting conversation: “He had completed hyperbarics and been through the wound care regimen,” Marvel related. “When he first started with us, he came to us in a wheelchair with a family member, and he was already an amputee on one side and had been ambulating with a prosthetic, but he had a [DFU] on the other, unaffected leg. That was concerning for him and his independence. By the time we finished his treatment and had him healed, he was back to ambulating again, using his prosthetic, and he regained his independence. That’s satisfying for not only the patient but also for everyone involved in his care.”
At the core of the Comprehensive Wound Healing Center’s mission is restoring patient functionality and independence. Oftentimes, the clinic recommends home nursing care despite the stipulations and homebound requirement impeding on the patient’s current lifestyle. “These elderly people who love to drive, go to bingo, go to the community centers, they’re unable to do that now because we’ve taken away a little bit of that independence,” Cahill said. “So, healing their wounds is nice not only because they don’t have to do dressing changes or worry about it becoming infected, but it’s also giving back their independence and ability to socialize in the community we’re very familiar with.”
Building a Multidisciplinary Team
Those patients’ experiences, adds Marvel, “speak to the importance of bringing the patient into the realm of helping themselves to heal and patient accountability, and working together as a partnership with the nurse and the physician in order to obtain the same goal.” The clinic’s staff finds that engaging the patient and their caregivers, as well as the community through talks and functions such as “Good Neighbor Day,” which is held yearly in September, helps build upon the need for multidisciplinary wound care.
In addition to her general surgery and wound care practices, Cahill works closely with the residency program at Roxborough Memorial. As rotations cycle through the hospital, she places an extra emphasis on wound care with residents who study under her. The goal is to educate future providers, no matter their specialty, so that the overall experience for patients living with chronic wounds improves. When those residents begin their careers, the patients now have a more comprehensive, multidisciplinary team behind their wound healing. With a trend towards educating in-hospital residents and patients alike, the facility emphasizes open communication with all assets of the patient’s care team. As most cases are referred from primary care physicians, the clinic wants to keep the patient’s first line of care open to all progress and changes. Follow-up letters, documentation with wound care progression photos, and post-visit phone calls involve the referring physician in this specialized field.
To complete the full complement of care, the clinic’s multidisciplinary staff includes two on-staff wound care nurses, Ma Aurora Hermoso, RN, and Melissa Groves, RN, who are significant to monitoring patients’ well-being and progress; an inpatient wound and ostomy nurse, Barbara Fleming-Brzycki, RN, CWON, who provides extra support and consultation; two podiatrists, Nekeisha S. Alexander, DPM, and Sabrina Minhas, DPM, who treat many of the lower extremity wounds; two interventional radiologists, David L. Smoger, MD, and David Feldstein, MD, who assist with in-center vascular work; and two vascular surgeons, Michael C. Marcucci, MD, and Dominic J. Bontempo, DO, who provide consultation and see many of the clinic’s patients outside of the facility. In addition, Roxborough’s wound care team credits the hospital’s staff nutritionist and physical therapy department for helping to complete the comprehensive patient care team.
“When it comes to our staff and our wound center, we’re a very tight-knit group, and that reflects in our patient care,” said Cahill. “Any patient who walks through these doors immediately knows everybody’s name here; when they call, they know to ask for Aurora, Melissa, or one of us. The primary goal, obviously, is to heal wounds, but we also serve our community and get to know our patients and the community they represent.” Of note, as well, is the hospital’s overarching leadership and support of the wound care clinic. Matt Shelak, chief executive officer, and Jacqueline Pester-Babcock, RN, MSN, chief nursing officer (who was on the ground floor of the center’s opening), provide institutional backing for the facility’s initiatives and care. Marvel explains, “the hospital administration support we receive is tremendous. They help keep the center going and thriving.”
Ways To Healing
As with all wound clinics, however, there are challenges and hurdles to overcome to achieve the best possible patient care. For this particular patient population, staff members find that finances and travel are the largest barriers to care. While younger patients may find it easy to traverse the neighborhood’s hilly landscape, elderly and non-ambulating patients can find the commute painstaking. While the clinic’s numbers and metrics are below the national average of days-to-heal, quality remains of the utmost importance. Quality report meetings occur weekly to ensure the wound care continues to meet the needs of the patient population as well as the requirements of payers like Medicare and private insurers.
“When insurance companies are talking about quality measures to get reimbursement, sometimes that can be difficult and hamstring us a little bit,” said Cahill. “We’re trying to do the right thing for the patient and trying to make sure that we’re kind of ‘throwing the kitchen sink’ at patients who truly need it, but sometimes we are limited in what we can do because of insurance companies and their reimbursement patterns. We can almost always find a way around it, but the bottom line is the right thing is being done for the patient.”
Marvel added that, “at the end of the day, a healed patient is more cost-effective for the insurance company than a patient who needs to access care, debridement, bandages, and all the supplies that come with it.” n
Lauren Mateja is associate editor of Today’s Wound Clinic.
1. Roxborough: our history. Roxborough.com. 2019. Accessed online: https://roxboroughpa.com/our-community
Marie Marvel, RN, BS, WCC –
Director of Wound Care
“When I started in wound care initially, I was a staff nurse. I moved into a management role, where I was clinically hands on here in the center with wound care and hyperbarics, and managed the day-to-day operations of the center. After many years of doing that, an opportunity presented itself for growth outside the hospital with a national managed wound care company. My primary role was to open a center in the vicinity. Six months later, I was promoted to a regional position, director of clinical operations, for their wound care centers. I had three states, which grew to five. I opened a lot of centers in this area and several other states, and trained the staff. While doing this, I thought to myself, ‘in little Roxborough, we had been doing [hyperbarics and wound care] for fifteen years; now other hospitals are just getting started with it. The Comprehensive Wound Healing Center was one of the first to start seeing it blossom.’ To go out and to be able to share that knowledge with others in other states was phenomenal. I got to share with physicians and nurses, get [new clinics] up and running, and then move onto the next one. But then I wasn’t able to reap the benefit of really knowing the difference you really did make on a day-to-day basis. When you’re here with oversight of one small department, you see the difference that you are making with the staff and the patients. At the end of the day, it’s all about the differences we make for our patients and that we help someone. If we can help someone, we’ve done our job.”
Catherine E. Cahill, DO –
Physician Medical Director
“When I first started medical school, I was convinced I wanted to be a primary care doctor. I loved interacting with patients, I loved building the continuity. During my third and fourth years of medical school, I determined that wasn’t really for me, and I knew I wanted to be a general surgeon because I loved being in the operating room and loved doing procedures. So, I did my general surgery residency and did a few outpatient rotations during those five years of training, and I worked in the wound care center at various facilities. The thing I liked about [wound care], and what drew me to Roxborough and our wound care center, is that you get that primary care feel. All of my patients come back; I know their stories, I know their kids, I know that they went on vacation three weeks ago. Wound care really fulfills that primary care aspect of medicine that I love.”