October 2003

Branching Out

By Renee Cordrey, MSPT, MPH, CWS

Wound care is an area of practice gaining awareness in many health professions, such as physical therapy. PTs have an important role to play in caring for patients with wounds. As a result, many facilities may be considering starting up wound care programs within physical therapy departments.

Three years ago, I started an inpatient and outpatient wound care program at a teaching hospital in Los Angeles. Within 6 months, two additional PTs were needed. Three years after opening, we are busy enough to support three and a half therapists and an aide. We have earned an excellent reputation among our colleagues and became profitable in approximately 6 months.

PROGRAM STRUCTURE

Providing wound care within a physical therapy department may take on the form of a structured program, or an informal structure where wounds are included as one type of condition seen by PTs in the facility. In either case, development of a program usually involves at the core a PT passionate about wound care.

An outpatient program is typically easier to start, involving only rehabilitation department staff and referring physicians. However, if the clinic is in a hospital, then an inpatient program should also be initiated. Even if a certified wound care nurse (CWOCN, formerly CETN) is available, physical therapy interventions are often a beneficial adjunct to standard wound care, and inpatient populations often have a prevalence of people with wounds. Due to a CWOCN shortage, many hospitals do not have full-time wound specialists. A second reason for inpatient involvement is as a source of referrals to an outpatient program. After discharge, many people receiving wound care need ongoing services as outpatients.

Determining who is involved in the wound care program must be individualized to the facility and personnel involved. Naturally, PTs, PTAs, and physical therapy aides are the key personnel. A more formalized program may need a medical director. The rehabilitation department’s medical director is a likely choice as the wound care program is part of the rehabilitation department. In some settings, the physiatrist is preferred as a neutral choice, someone who will not override the referring physician’s orders or “steal” the patient. Others may select a wound care physician, believing that it gives the program more credibility. A thorough assessment of the resources and the politics of the facility is needed before making a decision. Another option is a panel of physicians from several relevant disciplines utilized for case review discussions, quality monitoring, and referrals. Those panelists may be permanent or rotating.

Seeing patients with wounds is very similar to seeing patients with other rehab diagnoses. A physician refers the patient. After seeing the patient, the PT communicates with the physician to get approval for treatment. Because many people with wounds also need diagnostic testing consults by other professionals or durable medical equipment and orthotics, these recommendations are made.

Medicare and most insurers do not separately reimburse for dressings used during treatment. Those products are considered to be part of the cost of providing care. As wound care supplies may cost several dollars each, the cost can be significant when multiple products are needed at one time. Obtaining these supplies through the hospital’s purchasing contract may help reduce this cost. Insurance generally pays for dressings used at home by the patient between visits. Many dressing suppliers are willing to develop consignment arrangements in which the clinic stocks and issues dressings to patients, and the vendor bills the insurance company.

Whatever form the program takes, it is crucial that administrative support is strong. As with any new program, there is a ramp-up period until a large caseload is established. During that time, productivity for the wound clinicians will be low as they spend their time designing and marketing the program. Providing wound care is more costly than some other areas, due to the supplies utilized. However, the program can become marketable as the caseload builds. Administration must be willing to suffer a loss initially while awaiting future profitability.

PROS AND CONS OF A PT-BASED PROGRAM

There are many advantages to a physical therapy wound care program. If the passionate persons are therapists, then rehabilitation is the natural home for wound care. PTs are able to provide comprehensive wound care services to aid healing, encompassing exercise, gait training, mobility training, orthotic management, and therapeutic modalities in addition to direct wound care.

Physical therapy wound services can improve revenue. In an outpatient setting, revenue is directly generated. In an inpatient setting, the provision of wound care can improve reimbursement under DRGs for acute care and RUGs for skilled nursing care. Decreasing pressure ulcer incidence and speeding healing rates through optimum care can reduce the costs associated with supplies, nursing care, and complications such as infections. While difficult to quantify, cost savings are foreseeable. Additionally, improving a facility’s reputation as a quality provider can increase admissions and therefore revenue.

Physical therapy wound programs have political advantages. As insurers require physician prescriptions, the referring physician is still involved in the patient’s care. Therefore, there is no perception of patient “stealing,” which may exist with physician-based clinics. Physicians often feel safer referring their patients to a PT to retain some decision-making authority.

The primary disadvantage to a physical therapy wound care program is the fact that PTs are not commonly thought of as wound care providers. Much education must be provided to other health professionals regarding the skills and scope of practice of PTs in wound care.

Because PTs are not autonomous providers, referrals for testing, medication, and consults can be only recommended to the referring physician, not made directly by the PT. Those suggestions may not be followed by those with prescriptive power, resulting in frustration for the PT and a possible gap in patient care. When a referral to another physician is indicated, the patient may become managed exclusively by that physician, resulting in a loss of the case.

MARKETING STRATEGIES

As with any new program, promotion is critical to its success. The first step is to increase awareness. Using the existing communication systems is an easy way to start. Write an article for the facility’s newsletters. Speaking at medical staff meetings and providing in-services for physicians, residents, and nurses increase their knowledge about the program and services available. The program may also distribute its own newsletter to physicians, nursing units, neighboring hospitals, and long-term care facilities. Introductions of the staff, successes, continuing education programs attended, educational articles, and other items of interest may be included.

During these awareness activities, the specialists can promote their expertise. People often do not understand the wound care skills of therapists. Demonstrating their advanced knowledge, the therapists can advance the positive opinion of the wound care PTs and the treatment they provide. Anyone with the Certified Wound Specialist (CWS) designation from the American Academy of Wound Management (AAWM), a respected pan-disciplinary credential, should tout the expertise that it signifies. Citing evidence supports one’s actions and demonstrates clinical excellence and advanced knowledge.

Relationships with other health providers are crucial. If a provider has a good experience with the wound service, he or she will share that experience with others. The power of word of mouth cannot be overestimated. Many health professionals will accept an offer to shadow a wound specialist for a few hours. The specialist’s expertise is then demonstrated, the other professional has the opportunity to learn more about wound care, and a positive professional rapport is established.

Some physicians do not recognize wound care as a specialty. An effective strategy to gain physician supporters is to find a test case. After following an unsuccessful treatment plan for a week, the therapist may suggest to the physician that they try a different plan for a week, followed by a review of the progress. Very often, the wound will have significantly improved. After a few of these examples, the specialist’s credibility has grown, and the physician gains some additional respect for the PT’s skills.

Keeping outcome measures (eg, weeks to heal, area decrease/week, and area percentage decrease/week) allows the program to compare its successes with published data. If the program’s outcomes are comparable or superior, it becomes a great marketing tool.

HELPFUL RESOURCES

Several resources are available to aid PTs in advancing their wound care skills and developing a wound care program. The American Physical Therapy Association (APTA) has many services for members. The Private Practice Section and Section on Administration can assist with management concerns. The Clinical Electrophysiology Section has a Wound Management Special Interest Group that has been very involved in reimbursement issues relating to PT and wound care.

The AAWM is a multidisciplinary organization that issues the CWS credential. Clinicians must submit a portfolio with their application before they are allowed to sit for the board examination. All professionals must meet the same criteria.

The Association for the Advancement of Wound Care (AAWC) is the leading international, multidisciplinary wound care organization. The AAWC is involved in national policy issues, and provides educational resources for its members.

In the early 1990s, the Agency for Health Care Policy and Research formed expert panels to review the available evidence for a number of diagnoses. The Guideline for Pressure Ulcer Prevention and the Guideline for Pressure Ulcer Treatment are still considered current and have been used as a standard of care in litigation. These documents are available on-line. A number of other wound-related guidelines may be accessed through the National Guidelines Clearinghouse.

CONCLUSION

Starting any new program is challenging. Building a wound care program faces additional challenges, including low public awareness. But physical therapy has an important role to play in wound care. Many therapists are willing to fill that need, with the support and patience of management.

Renee Cordrey, MSPT, MPH, CWS, is wound care clinical specialist, White Memorial Medical Center, and instructor, doctor of physical therapy program, Mount St Mary’s College, Los Angeles.