For more photos from our visit to Excela Health, visit http://www.todayswoundclinic.com/slideshow/facility-focus-photo-slideshow-maximizing-collaboration-develop-wound-care-service-line-ex
Greensburg, PA — On a sun-soaked afternoon last summer, Anna K. “Kay” South, FNP-C, MSN, CCRN, received a phone call that would forever change her career. Uncommonly hot that day for the Pittsburgh suburb, the temperature was enough to convince South to retreat into the nearest building to answer her cell as she strolled across the campus at Excela Health. Calm, collected, and, yes, now cool enough to recognize that she had stepped into the entry way to the health system’s Advanced Wound Center to take the call, South serendipitously remembered hearing that the clinic was in search of a nurse practitioner to augment its daily clinical operations. The call all of a sudden didn’t seem so important.
In a matter of moments she was off the phone and inquiring about the position, which she assumed would be a perfect fit for her desire as a newly minted NP with a background in critical care and home care to treat a patient population that would benefit greatly from her clinical experience in a setting that would give her the chance to provide hands-on care where positive outcomes are overwhelmingly the expectation.
“I figured that my background in the ICU and critical care, where rapid responses were needed for people who were very sick and taking care of the ‘whole person’ was not new to me, that this could be a good fit,” South explained during a recent visit by Today’s Wound Clinic to the outpatient center, a 5,000-square-foot facility established in 2003. “So, I ducked in, spoke to the receptionist who confirmed that they were looking for an NP, and it all came together.”
Today, that theory of togetherness remains as South has comfortably made the transition to her still relatively new position, which has required her to gel with an existing staff of more than 20 professionals that includes a longstanding, six-member panel of specialty physicians and surgeons as well as more than 10 registered nurses. Through the utilization of a case management model of care, she and the staff have also jointly reached some lofty wound healing metrics established as part of the health system’s initiative to expand its wound care services while formulating a continuum of care service line that revolves around the wound clinic. The validity of this benchmarking success is evident in what the last three years has produced: the most productive clip of healing rates the clinic has ever seen.
“We want to have 80 percent of our patients 100 percent healed within 16 weeks — that’s our metric,” said Tom Capco, system director of ambulatory and outpatient services at Excela, a title that includes management of the wound clinic. “Right now we’re running at 82 percent. And with a 16-week timeframe for who we see here and the high population of diabetics that we have living in this region — I think that’s wonderful.”
Equally impressive has been the clinic’s method of adapting to a significant level of change across a host of clinical and business perspectives since Capco took over the daily operations of the center in fall 2011. It’s a series of modification that’s been enabled by a dedicated team approach carried out by a determined group effort.
“Teamwork makes this place go,” said Scott Jacobson, DO, internal medicine specialist and physician panel member. “Everyone is well respected. Nobody is more important than anyone else. That’s what makes us so successful.”
Champions of Change
It was a completely hypothetical situation that Capco feared as he initially surveyed the landscape of his clinic upon his own transition from an Excela inpatient department (see sidebar) that served as the impetus for enacting what would soon lead to a widespread remodeling of wound clinic protocol and practice to attempt to meet the quality standards that had been set. The vision: an overcrowded waiting room filled with patients awaiting care by an overwhelmed healthcare staff.
“With the number of patients we were seeing and the metrics we had been striving for, it was conceivable to think that if we had a full lounge and the surgeon who was supposed to be in clinic was stuck in the operating room all afternoon, our customers could also be stuck waiting — and that’s not the kind of service we would want to provide,” he said. “You wouldn’t want people leaving because they’re frustrated — that’s not what we’re about. And you certainly don’t want to lose that revenue, so the bottom line is that you have more continuity of care in practice when you have someone in the clinic full time every day.”
Enter South, a nurse of nearly 40 years, who in her role serves as the clinic’s sole full-time provider who assists in the care planning coordination of the more than 30 (on average) patients seen in the clinic each day, which has resulted in as many as 100 new admissions in one month’s time over the course of the last three years. Her appointment marked the first time since the clinic had been built that the physician panel would not be exclusively relied upon to rotate oversight of the wound patients’ care.
“We’ve always had a panel of physicians from a multitude of practices in place, and they’re all vested, loyal providers, but nobody ‘owned’ wounds here, if you will,” Capco explained. “So, to really get better continuity of care, she’s been a great addition to our staff as an experienced ICU nurse who is also comfortable working with the home care staff to facilitate and expedite orders on anything else that may be needed in the home right away, which can save the patient an additional trip to the clinic or the hospital — a potential barrier that we avoid. And there’s great respect and camaraderie between her and the staff in the clinic. It’s been a smash hit for the nursing staff because they also have that direct access to a provider all day long if they have questions or need assistance with our patients.”
David A. Kenney, MD, a member of the physician panel who also serves as the clinic’s medical director, agrees, adding that South has just as easily forged a constructive collaborative relationship with the physician group as she has with the nurses. As the medical director, he has a particularly close affiliation with the NP.
“By having Kay in the clinic each day, we have a paradigm in place that allows us to see every patient on a weekly basis unless they’re palliative,” he said. “We meet regularly to discuss our patients’ needs and consult one another on our care planning — and it’s just been an extremely productive collaborative between the two of us and the nursing staff as a whole. And that’s one of the keys to our whole system working well.”
On The Case
That system refers to the clinic’s case management approach, in which each patient is provided with a primary physician depending on the specialty required per the wound as well as a consistent RN who remains involved with patients as the physician’s “case manager” throughout the care trajectory in an effort to foster familiarity and supportive relationships for both patient and provider. In this vein, South’s direct coordination with the physicians will often see her rotate in on patient visits when panel members are in surgery or private practice.
Additionally, South’s scope as an NP allows for her to conduct comprehensive assessments of each patient at admission (along with the assistance of an assigned admissions nurse) and to order all needed diagnostics without the presence of a “supervising physician” onsite. At discharge, the patient then receives an assigned exit nurse so that any questions post-care can be streamlined and supported by continuity among South and/or the physician and the RN.
“The case manager model allows us to be very collaborative and allows the nurses and the physicians to communicate with the patients together as we pursue things like vascular intervention, or changing dressings, or ordering specific tests, or getting a nutritional assessment,” said Susan Poklembo, BSN, CWCN, wound clinic supervisor.
A member of the clinic staff for 11 years, Poklembo has witnessed the modifications that have occurred at the wound center from a unique vantage point and has realized the rewards of an effective collaboration in care on various fronts.
Upon the correct diagnosis at Excela, the patient’s recovery actually bested the stringent metrics standards by a few weeks. According to Kenney, while the experience was quite unique, the rate of satisfaction expressed to him by the vast majority of patients and their families at the clinic remains consistent.
“I get a lot of feedback, and what I hear is that people are extremely happy with how things are run here and the quality of care,” he said. “And the reason that we’re able to help them get better in a short period of time is that we work well together as a staff, we communicate with one another, and the understanding of patient care is the fuse for everyone. It’s just a nice setting, and I’m fortunate to be a part of the job that people are doing here.”
In spring 2013, Kenney and Poklembo, as his wound care case manager, were honored by the health system with a quarterly Hospital Teamwork Award, which recognizes the collaborative efforts of a physician and an RN based on overall mission-driven values to clinical care. The award is considered just as much a positive reflection on the clinic as a whole as it is the provider pair.
“It’s just another way of recognizing the care we’re doing here and at Excela that we all get, because we’re part of the same team,” Capco said.
Emphasis on Expansion
The clinic’s reputation within the health system is also solidified in its plans to expand wound care into an additional outpatient clinic this May in Mount Pleasant, PA, along the region’s “Route 119 Corridor” as well as its emergence as a “hub” for what has become and will continue to be an evolving service line of care that includes a diabetes center and will soon envelop sleep services.
Currently coordinating sleep care through a vendor-line model that sees Excela already responsible for the capital and three laboratories while an outside party manages scheduling and care services, Capco said he has initiated the transition to centralize everything within the Greensburg location because it makes more sense logistically from a business sense and as a means to help improve on those healing metrics they continue to examine.
“It’s simple logic: You need glucose control and optimal oxygen levels to heal wounds,” he continued. “And some of these patients we’re seeing are dropping down to the 60s in their O2 saturations when you want to be 90s and up. There are cardiac issues that can develop if you have untreated sleep apnea, so we’re looking at it from the whole continuum of care from a system perspective.”
With the expected continued success of healing rates, however, it’s actually plausible that patients will have their particular wounds healed prior to going through the protocol of two sleep studies to properly diagnose those who are referred for sleep services based on their admissions assessment. As such, Capco envisions patients to be more compliant with their sleep health with all services localized in one setting.
“When we’re healing wounds in 10 weeks, for patients to get through their studies and have any needed equipment set up at home by our durable medical equipment service — it’s not going to impact the wound they came to us with on that timeline, unless, for instance, you’re talking about a palliative care patient with a coccyx wound,” Capco continued. “But we’re doing what’s right for the patient overall.”
The same holds true with diabetes care, which initially ran independently, but is now tied to the clinic through a process that includes an assessment by a certified diabetes educator (CDE) when appropriate candidates are identified.
“If you let a patient who’s living with diabetes leave your building without getting introduced to that CDE, you’re lucky if you have a 25 percent chance of them coming back in to get their education,” Capco said.
The nearly finalized expansion has been necessitated by the number of patients currently being seen in Greensburg from as far out as the Westmoreland/Fayette County border, a region south of Pittsburgh that’s especially known for its prevalence of diabetes, many of whom were referred to the clinic through an RN liaison program that brings clinic nurses into private practices and other healthcare settings to educate providers on the services and structure of the clinic (see sidebar). The new clinic will function with existing staff rotating along with the addition of another NP, will add three exam rooms to Greensburg’s eight, and likewise develop into a hyperbarics center after need is evaluated. The new facility will also allow for more local referrals to be accommodated in Greensburg.
“Once you open that center, you hope it will be a feeder for you for new business, but to backfill the void that will be created by taking people out of this center — and there will be a void — that’s where marketing comes in,” Capco said. “Our marketing team is phenomenal. They’ve done TV commercials, billboards — whatever we need from them. And when I say ‘we have a great team here,’ the senior administration is part of that. We’ve got a great group of people, and I know a lot of clinics and health systems will say that because you have to be if you’re going to provide great wound care, but I’m very proud of the people we have and couldn’t ask for much more.”
Joe Darrah is managing editor of Today’s Wound Clinic.