Editor's Note: Dr. Scott Bolhack, MD, MBA, CMD, CWS, FACP, FAAP, shares the issues and complexities he's seen in patient transitions across care settings like post-acute hospital and hospice care. Through the "Wound Provider Checklist" he presented at SAWC Spring 2023, Dr. Bolhack hopes this tool simplifies the complexities of patient transition through care.¹

Transcript

What specific issues in patient transition across the care continuum have you seen?

Scott Bolhack, MD, MBA, CMD, CWS, FACP, FAAP Wound care across the transition of care space right now is extremely challenging, and this has to do with some of these issues of variability of the health care providers. Again, we have doctors and nurses and nurse practitioners and physician assistants delivering care, but we also have nurses delivering care in some of these settings only. And then when we try and understand the level of expertise of each one of these and each one of the clinicians that are delivering care, that becomes really difficult to understand. And we really only have 1 formal training program in the United States of America. That's the Wound, Ostomy and Continence Nursing. It's the only formal program really we have. We have all other kinds of certification programs, but right now they're really in flux. And what it really means to have these initials behind your name can constantly be challenged because of so many of these different certification programs, it makes this very, very difficult for the consumer. And then in each one of these silos, you have to say to yourself, do we really have enough wound care experts in all of these places to really deliver the quality of care that we need? It is only 6,500 WOCN nurses. I don't know how many certified CWS and CWSP professionals that we have. I don't know how many WCC professionals we have. But when you look at 15,000 nursing homes and 2,500 hospitals and add the rehab hospitals and long-term acute care hospitals and the 6,000 hospices and the 12,000 home health companies, you run out of experts pretty quickly. Then within each one of these silos, the hospital, the rehab hospital, the long-term acute care hospital, the skilled nursing facility, home health and hospice, so those reimbursement systems clearly control what's on the formulary in those facilities and clearly control some decision making on your part in terms of what the patient's going to receive in terms of wound care products. And then here comes the difficulty as the patient moves from a hospital where they're only there for whatever the average is, let's say 3.2 days, and now they move to a different setting. They're going to probably get that that same health care professional is not going from the hospital over to the nursing home in practically all cases. And then if they go from the skilled nursing facility to home health, again, they're going to wind up with a different person taking care of their wounds. So as a person goes from one silo to another and has a change in products and a change in providers, care has to be affected. And each one of those decisions in terms of the treatments and the knowledge base are just open variables. It's difficult enough to try and understand that as a health care professional, I can't imagine what it's like for the patient. I can't imagine what it's like for the patient's family. They can't even advocate. And some of this gets really complicated. Really complicated really, really quickly. If you have a negative pressure wound therapy device in the hospital, sometimes you can't leave the hospital with that therapy device. So you have to then go to an outpatient wound center and then have the same product reordered for you so that you can be in the home setting. When I was in the outpatient wound center, patients would come in with a bucket of wound care products and spill it on the table and you'd sit there and you'd go, "Oh my God! How confusing can this be for the individual when they have all these products? How could they know what to possibly put on their wounds?" And then there are some real specific things. For instance, what's reimbursed and not reimbursed. Once, if you have a diabetic neuropathic ulcer that required surgery and it's not healing properly, and you're eligible under all criteria in the outpatient setting for hyperbaric oxygen, for example, if you're in a skilled nursing facility on the Med A stay, the chances of you receiving hyperbaric oxygen are not 0 but pretty close to it, even though you're eligible for that. Why? Because the reimbursement for that hyperbaric has to come off of your Med A stay from the skilled nursing facility, and they're only getting, that's $400 a day. The nursing home's not going to pay for that. But even more importantly, I guarantee you the typical primary care clinician that's now taking care of that resident in the skilled nursing facility, they don't even know enough to say, "Oh, this patient should be getting hyperbaric oxygen." It's a high level knowledge base that you would need to do that. And so we can provide dozens and dozens of examples of this, of the frustration it is for the patient as they go through the system. And each one of these has their own different reimbursement and therefore your decision making becomes isolated. I think my last comment would be that if you had a heart problem and you were in the hospital, congestive heart failure, your cardiologist would follow you through each one of these entities. You would always go back to the cardiologist. And we don't have that model for wound care in most cases in most systems. There are exceptions, but in most cases, you're going to be followed by multiple wound care clinicians, and I'm including nurses in that term clinicians, throughout your entire transition of care. And you're going to have all this variability, multiple products being used, and no one's actually taking ownership. And we expect the patient and/or their family to understand that. And that's what this group is all about. So a new group was formed, it's called the Post-Acute Wound and Skin Integrity Council, known as PAWSIC, and we began meeting about 2 years ago under the leadership of Jeanine Maguire and Sarah Holden now, and we're a group of about 19 professionals right now, multidisciplinary. We're here to really advocate ultimately on behalf of the patient and the family to get the best care that they can, to help advocate for them. And so this is what this, putting together this wound care provider group question is. This list of questions can be used by patients, by family. They can be used by skilled nursing facilities. They can even be used by outpatient wound care departments. And they can be used by this new phenomenon of these new wound care groups that are trying to go into skilled nursing facilities to say, "Are we meeting some bar here? What are our holes?" We acknowledge that on this list, the larger list that we've put together, that very few groups are able to, if any, are able to hit every single bar. But there should be a standard and there should be a level of understanding of what it's like to deliver the best care that you can in any one of these settings. Reference

1. Bolhack S. Wound Provider Check List — A Decision-Making Guide for the Transition of Care. Poster presented at: SAWC Spring 2023; April 26-30 2023; National Harbor, MD

About the Presenter Scott Bolhack, MD, MBA, CMD, CWS, FACP, FAAP, is an internist in Tucson, Arizona and works in hospice and palliative care. He has worked in the wound care space for upwards of 25 years and started in skilled nursing facilities. He’s practiced across the entire transition of care, including assisted living facilities, home health, and wound care in hospice. Over a period of 12 years, he was the medical director and practicing physician at hospital outpatient department of wound care, along with 2 nurse practitioners. Now, he is a regional medical director for a nursing home chain and still practices wound care at a local nursing home. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies