On the provider side, we see dilemmas in wound care delivery. Each care setting has different incentives, regulations, reimbursement and payment systems, as well as conflicting strategies and interests. Oftentimes, this results in “gaming” the system, which ultimately is not in the best interest of the patient and fails to improve patient outcomes.
Tied to this are challenges wound care nurses face trying to provide care to patients day to day. Let’s start with practice patterns: It’s not uncommon for wound care nurses to encounter “we always do it this way here” attitudes in various care settings, even when these “ways” are not considered best practice. Also, cost coverage of wound care dressings varies across the care continuum. Medicare reimburses the acute care hospital, long-term acute care hospital (LTCH), and the skilled nursing facility for all routine, ancillary and capital costs, including surgical dressings, under the Medicare Severity Diagnosis Related Group (MS-DRG), long-term care hospital (LTCH-DRG), and resource utilization group (RUG) prospective payment system rates for Medicare Part A stays, respectively. At home, Medicare Part B, an elective benefit, will typically cover 80% of the costs for surgical dressings and the patient may be obligated to cover the rest if they don’t have a supplemental plan. Coverage by Medicaid and private insurers vary widely by state and plan respectively, and in some cases may leave the patient with a substantial out-of-pocket balance.
In the meantime, clinicians are finding themselves working in silos, where the exchange of information from care setting to care setting is out of balance for numerous reasons. Often, there is a lack of complete information about a patient upon transfer, including the absence of goals for recovery and/or plan of care. A patient’s health history is oftentimes “lost” or incomplete. Follow-up diagnostic testing is spotty, leaving an inaccurate, incomplete or insufficient picture of a patient’s condition at transition. In the meantime, coordination with clinical specialists from care setting to care setting is generally poor, also resulting in unnecessary visits.
With elderly patients, who represent a large population of chronic wound patients, comes additional complexity. They typically require medication reconciliation. And, they are not familiar with or they are intimidated by electronic personal health record systems, failing to maintain and manage their health information as a result. The opportunity and potential for better outcomes is higher when family members or close friends are involved in a patient’s care, however, this isn’t always the case.