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All About that Biofilm

As Jennifer Hurlow, GNP, CWOCN, highlighted in the February Journal Club Presentation “Diabetic Foot Infection: A Critical Complication,” the science is there, but clinical practice – often – is not. Evidence suggests that approaches to treatment for chronic wounds that incorporate biofilm research, like Biofilm Based Wound Care (BWCC) can lead to significant increases in the efficacy of treatment of chronic wounds, but most traditional diagnosis and treatment methodologies overlook the importance of biofilm in wound healing. So how can YOU help make the transition and bring more of these evidence-based practices into the wound care community?

Read Up. For a start, AAWC members can review the recorded webinar and hear about some of this research from Jennifer, first hand, by logging into AAWConline.org. Or, the article was originally published by the International Wound Journal and you can access the full text there with a subscription.  Equip yourself with a thorough understanding of the research so you and your teams can better use it to inform your practice.

Join the Conversation at the upcoming Wound Infection Summit Atlanta. Jennifer and several other researchers and clinicians with BWCC expertise will be sharing their insights, practices and tactical approaches as a part of the program. Not only that, the summit includes additional conversation on gaps between scientific research and clinical practice, helping share practices and new ideas across disciplines. Learn more and register today for the WIS Atlanta!

Reach out. Who are the fellow healthcare professionals you interact with regularly in your community that you “only wish more fully understood and appreciated the great information that is available”? Invite them to membership and engagement with the AAWC. The more diverse healthcare providers are included in this multi-disciplinary wound care community, the better the results… if you’re not already a member, join today and invite those you work with to join!

Why Sponsors Matter

AAWC walks a careful line toward assuring balance for members. Policies have long been in place to prevent organizational endorsements of any businesses or corporations or products associated with wound care. Additional policies assure the AAWC leadership does not benefit financially from relationships with wound care businesses. The AAWC expects and offers transparency, and holds both leadership and membership accountable.

And yet at all Summits, there is an exhibition hall of sponsors members and summit attendees are asked to visit. The sponsors are there because they have been invited by the AAWC or they have asked and paid the AAWC to participate. It may seem a violation of the organization’s very tenets. But it isn’t and here is why.

On the front lines of wound care in clinical settings across the country and around the world, members need the very best tools available to successfully treat patients under care. It is not possible for individuals or even individual institutions to remain on the cutting edge of all things new in wound care. Having developers and manufacturers of tools, treatments, practices, and devices willing to participate in a Summit helps advance wound care. It enables care providers to do what they do best, confident in the knowledge they have what is new and best.

Removing vendors as sponsors and exhibitors would limit the potential of providing best in class care for patients in need of healing. These opportunities for engagement one-on-one with those most familiar with innovative healing tools are crucial to advance wound care. AAWC Summit attendees and all members can trust that policies prevent inappropriate relationships and can use the time to learn how the newest options can help in the clinic.

John F. Kennedy was Correct!

At a White House dinner for Nobel Prize recipients, President Kennedy said, “I think this is the most extraordinary collection of talent, of human knowledge, that has ever been gathered at the White House - with the possible exception of when Thomas Jefferson dined alone.”
A more than appropriate reference to President Jefferson, a man who was a statesman, a visionary, an inventor, an educator, a lawyer, a farmer – and many other things.

And on April 26-27th at the AAWC Wound Infection Summit, the same concept is likely to apply. On those days in Atlanta, some of the brightest minds and advanced care givers in wound care will gather to share expertise on a range of topics as vast as Mr. Jefferson’s accomplishments.
It is there when attendees will learn about the cost of wound care, the gaps in research and practice, how to bring research to the bedside, various approaches to wound care, how radiology is used in wound care, the impact of topical treatments on wounds, and the necessity of a systemic approach to wound treatment, among many other topics.

Like the Nobel recipients listening to Mr. Kennedy, the Summit attendees will hear from those most connected with advancing these matters in a practical environment. Registration is open at WoundInfectionSummit.com. Don’t miss your chance to join the best thinkers and practitioners in wound care.

In coming weeks, the AAWC will share speaker highlights and new research findings of the Wound Infection Summit – Atlanta. Stay tuned!

Meeting Makes a Difference

When it comes to treating wounds and providing best in class care for patients with wounds, none can go it alone. And with the numerous and different medical professionals typically involved in the care of any one individual, unique perspectives come to the bedside to develop a comprehensive treatment plan. Best outcomes result from cross-professional collaboration.

This is one of the many reasons why the AAWC Summits are crucial to advancing wound care. Those attending find an emphasis on audience interaction during the educational sessions, in the exhibit halls, and at the breaks. Speaker presentations are interesting and professional, engaging with the audience, sharing their experiences, and inviting the audience to do the same.

Professionals in all segments and levels of wound care gather to think, to listen, to share, to learn. A recent AAWC Summit focused on care and treatment of pressure ulcers. There was increased attendance from the previous year, with feedback indicating nearly all respondents found the sessions met or exceeded their expectations. Participant evaluations referred to the meeting as “thought provoking”, “interactive”, “evidence-based”, “cutting edge”, “relevant” and “practical”.

Among the most well-received program elements was the newly included patient success stories. Several patients benefiting from wound care specialists shared the challenges and triumphs of their wound healing journeys. In this video, wound care patient Tom Barnard shares his experience with the complications of paraplegia and how the support of a caring wound care clinician and family helped him overcome the associated pressure ulcer challenges.

The AAWC plans four additional regional Summits for 2019: three comprehensive wound infection summits and one lower extremity summit. In addition, the AAWC has been invited to develop a specialty advanced wound care track at the global summit for Complex Cardiovascular Catheter Therapeutics (C3), and others at DFCon 2019 and Desert Foot conferences focusing on wounds to the feet. You may view the full line up of AAWC Summits and Invited Tracks online.

There is no profession which benefits more than medicine from collaboration and sharing best practices and lessons learned. The AAWC Summits create professional forums for these exchanges. Participating is crucial to advancing wound care and advancing our collective roles in improved patient outcomes. February’s Pressure Ulcer Summit reached maximum enrollment and the upcoming summits are sure to fill quickly. Registration for the April Wound Infection Summit is now open. Make plans now to join us! Click here to register.

The Value of Coming Together - Part 2

Last week I told you how fortunate I was to attend the AAWC’s 2nd Pressure Ulcer Summit (PrU Summit) in Atlanta. Along with three colleagues and nearly 200 others, we learned about the latest research, thinking, and best in class approaches to the challenges of managing pressure ulcers. Today I wish to share a few of the key learnings I took away from the Summit.
 
Day one of the conference brought a lot of excitement about the topic of pressure ulcers.  In the room were researchers, physical therapists, physicians, surgeons, nurses, nurse practitioners, product specialists, and administrators from across the world.  The first presentation gave us a patient’s perspective on the issue of pressure ulcers. That set the stage for the remainder of the conference.  An important feature of the PrU Summit was learning how to make pressure ulcer prevention and treatment meaningful to the patient and individualizing care plans and treatment modalities. The remainder of the day was filled with research information on pressure-induced tissue damage both at the micro and macro level.  Most compelling was the research on offloading, including important patient considerations when determining how to offload and the choice of an offloading device to best fit the clinical situation.  
 
I also enjoyed being able to spend time with the pharmaceutical and wound care product vendors during the exhibit hours. It is important to nurture positive collaboration with corporate supporters and vendors. These interactions provide a mutual benefit. Companies can learn more about the challenges we face in wound care practice, taking this information to their teams to improve and advance product development in support of clinical practice and patient needs. In turn, these companies provide clinicians with important research and data to help drive evidence-based practice.  
 
Using the detailed research information from Day 1, the second day brought it all to a practical level.  One of my favorite sessions was the Topical and First Line Treatment program with Kelly Jaszarowski, MSN, RN, CNS, ANP, CWOCN & Stephanie Yates, MSN, RN, ANP-BC, CWOCN, which included ample audience participation. It is so good to hear from a room of clinicians what their practice, experience and opinions are, and then to have that conversation brought back to where the evidence is for those interventions. This interactive program also spawned a great conversation on wound cleansing, wound infection and biofilms, providing AAWC President Tom Serena the opportunity to remind attendees there is more to be learned at the Wound Infection Summit planned for April 26-27, 2019 back here in Atlanta.
 
There were many other take home points and practical applications offered including when surgical interventions for pressure ulcers are warranted; post-acute care considerations including choice of facility; the role of the outpatient wound center in navigating the treatment plan; and tips to secure insurance coverage for durable medical equipment. And that is where the information learned and experiences shared during the PrU Summit take us from here.  Participants left armed with new ideas and strategies to apply in their practices when they return to work. The PrU Summit also spawned research ideas to address new treatment and patient care questions that arose from the presentations and conversations. Wound care requires good research and guidelines that enable us to prevent and treat pressure ulcers while individualizing the plan to each patient, our staff, and our institution.  I invite all of us to come together to take a place at the table at future AAWC summits to discuss the questions, challenges, and research surrounding pressure ulcers.

The Value of Coming Together - Part 1

This past weekend I was lucky enough to have my hospital (Reading Hospital, part of Tower Health System) support the attendance of not only myself, but of three additional nurses from my institution at the AAWC Pressure Ulcer (PrU) Summit. Amy, the nursing quality coordinator, Sylvia, a surgical Intensive Care Clinical Nurse Specialist, and Eileen, the medical intensive care unit clinical nurse specialist are NOT wound care specialists.  The vision of our institution is that engaging the entire team will help us drive change that is meaningful, hence my decision to have our team join me at the AAWC PrU Summit.  

My team and I found ourselves in the company of more than 200 clinicians representing institutions across the U.S., including individuals and teams from many practice areas and professional levels. In addition to attending the conference, we also attended the Pre-Summit Workshop titled PrU Prevention Programs: Justify, Quantify, Strategize.  There we heard from an international team that practices in a variety of settings that face challenges very similar to ours in the states. 

One of the greatest things about this conference is that we are not here to complain about the problems of our specialties.  We all know the challenges of patient care and of our practices.  Everyone in the room is here for solutions and to discover what other colleagues are doing that works well.  We learn about how external factors such as regulatory bodies, scientific studies and other published works can augment or hinder our practices.  As a wound care specialist, I was concerned whether my Tower Health colleagues would find the Summit beneficial. My passion for wound, ostomy, and continence care drive my desire to learn more. I should not have worried. Each reported learning something different but applicable from the Summit and agreed they would bring back learnings which would help in their day to day practice areas.  

There is extraordinary value in coming together. In listening to the challenges of others and learning how they have persevered through them and how our contributions and experiences can help others. Joining with researchers, physical therapists, physicians, surgeons, nurses, nurse practitioners, product specialists, and administrators, among others, we continue to drive the ever-changing and ever-improving specialty of wound care. And that is what I appreciated most about this conference.  You don’t know what you don’t know until you know what you don’t know.  

There is more to share about the take-aways from the Summit. Read more in next week’s blog!

What the Future May Look Like for Reimbursement

What the Future May Look Like For Reimbursement: A New Bundled-payment Demonstration Model  “Bundled Payments for Care Improvement Advanced” (BPCI)
By Peggy Dotson

Over the last several years, you may have heard of, or participated in, various models for payment consolidation or episodic-payment approaches considered by the Centers for Medicare and Medicaid Services (CMS). One of the most important goals at the CMS is “fostering an affordable and accessible healthcare system that puts patients first.” 

The latest model demonstration by the CMS began October 1, 2018 with multiple entities signing agreements (1,299) with the CMS to participate in the new “Bundled Payments for Care Improvement Advanced” (BPCI) model. This new federal bundled-pay initiative aims to improve patient care in both hospitals and post-acute care while lowering overall costs. A bundled payment methodology involves combining the payments for physician, hospital, and other health care provider services into a single bundled payment amount.

The first cohort of Participants began on October 1, 2018 with a model period performance to run through to December 31, 2023. Participants include 832 acute care hospitals (including Trinity Health, Adventist Health System and Tenet) and 715 physician group practices. (See Attachment A for full list). The CMS will provide a second application opportunity in January 2020.

How the New Bundled Payment Will Work

The participating entities will receive bundled payments for certain episodes-of-care as an alternative to fee-for-service payments, which was authorized through Section 3021 of the Affordable Care Act.

BPCI Advanced aims to encourage clinicians to redesign care delivery by adopting best practices, reducing variation from standards of care, and providing a clinically appropriate level of services for patients throughout a Clinical Episode. This single payment amount is calculated based on the expected costs of all items and services furnished to a beneficiary during an episode of care. The intent of a single bundled payment to health care providers is to motivate health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care.

Healthcare providers receiving a bundled payment may either realize a gain or loss, depending on how successfully they manage resources and total costs throughout each episode-of-care. This concept is not too dissimilar to the current Home Health Prospective Payment for a 60-day episode-of-care.  

A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.

BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare fee for services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary during the Clinical Episode, including outlier payments, will be part of the Clinical Episode expenditures for purposes of the Target Price and reconciliation calculations, unless specifically excluded.

Under the new BPCI Advanced demonstration, the CMS will pay providers a known fixed amount for an episode-of-care.

  • The episode-of-care could start with an initial hospital admission or an outpatient procedure and includes all care during the next 90 days.
  • Providers will be paid a benchmark price and can keep savings minus 3%.
  • Savings payments will be adjusted based on performance on seven quality measures. The Quality Measures selected for the BPCI Advanced model include:
All-cause Hospital Readmission Measure (NQF #1789) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)
Advanced Care Plan (NQF #0326) Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881)
Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) AHRQ Patient Safety Indicators (PSI 90)
Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)  

NOTE: The All-cause Hospital Readmission Measure and Advance Care Plan are required for all Clinical Episodes. The other five quality measures only apply to select Clinical Episodes.

  • If the participant exceeds the target amount, they would be penalized up to 20% of costs.

Hospitals and doctors can now receive bundled payment for up to 29 different clinical episodes. The 29 Inpatient Clinical Episodes includes:

Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis Gastrointestinal obstruction
Acute myocardial infarction Hip & femur procedures except major joint
Back & neck except spinal fusion Lower extremity/humerus procedure except hip, foot, femur
Cardiac arrhythmia Major bowel procedure
Cardiac defibrillator Major joint replacement of the lower extremity
Cardiac valve Major joint replacement of the upper extremity
Cellulitis Pacemaker
Cervical spinal fusion Percutaneous coronary intervention
COPD, bronchitis, asthma Renal failure
Combined anterior posterior spinal fusion Sepsis
Congestive heart failure Simple pneumonia and respiratory infections
Coronary artery bypass graft Spinal fusion (non-cervical)
Double joint replacement of the lower extremity Stroke
Fractures of the femur and hip or pelvis Urinary tract infection
Gastrointestinal hemorrhage  

 
The Three Outpatient Clinical Episodes includes:

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion

Reconciliation will be a semi-annual process where CMS will compare the aggregate Medicare Fee For Service (FFS) expenditures for all items and services included in a Clinical Episode against the ‘target price’ for that Clinical Episode to determine whether the Participant is eligible to receive a payment from CMS, or is required to pay a Repayment Amount to CMS.

This demonstration, which runs through December 31, 2023 will be the basis for a Go or No-Go decision to expand the demonstration, or expand the clinical episodes as part of the demonstration (could include wound care related clinical issues) or, enacting regulations to change the way hospitals and doctors will be paid for select clinical episodes.  

Conclusion

All in all, the CMS is continually evaluating more efficient ways to pay providers (hospitals, physicians/ other qualified healthcare providers) and suppliers for the healthcare services of the Medicare and Medicaid population. It is likely that certain wound care clinical episodes, especially in the outpatient setting, could be selected by the CMS for evaluation as part of this demonstration in the future.  It may be wise for wound care specialists to begin to look at their population of patients and understand the common aspects and deliverables of the care they receive across a 90-day period, as a marker for a potential ‘episode-of-care’ model. Better to begin to think in this vain rather than be blindsided a few years down the road.