Infectious Thoughts

    The patient seated on the exam table surprised me. I had seen him many times at hospital meetings and charity events. I quickly double checked the cover sheet on the chart to confirm his high-level connection to the institution. He presented to the wound clinic with a venous leg ulcer and wanted to enroll in one of our clinical trials. He appeared to be a candidate: My examination determined that the wound was not clinically infected, documenting a complete absence of signs and symptoms in the source documents.  The trial required a quantitative tissue culture biopsy, which I performed before placing him in compression. The following week the culture report revealed infection with a high bacterial load. Treating him with topical antimicrobials sped up his healing and he went on to complete closure in 6 weeks.

    Reflecting on the shortcomings of my clinical examination in this case led me on a career-long interest in improving lessons learned from a case such as this: the clinical signs and symptoms of infection in chronic wounds are unreliable, critical colonization is an ill-defined term, and bacterial counts may not tell the whole picture in chronic wounds. The journey continues, promising many more twists and turns as we gather more information.

    The AAWC leadership and membership agrees that this is an area that deserves focused attention. In response, we have planned a series of Wound Infection Summits for 2019. The summits will examine the current state of the art diagnostics, antibiotic stewardship and opportunities for future research. The first Summit is planned for April 26th and 27th in Atlanta and will be hosted by the Piedmont Atlanta Hospital. If you have an interest in this rapidly changing area of wound care, join us. Stay tuned to the AAWC website for program and registration information coming soon.

I challenge any nursing, medical or other specialty to surpass Wound Care providers in passion for their work or dedication to their patients. We are a special breed of clinicians with a unique passion for our work and dedication to our patients. However, uniqueness comes with a price: an obligation to advance wound care beyond its rudimentary beginnings. The AAWC has dedicated itself to providing forums that challenge the status quo, promote new ideas for practice and research and, most importantly, share information that immediately enhances the care we provide to the patients that so desperately need our expertise. To advance as a specialty our educational programs must not focus on novices and consist of redundant sanitized content; it requires open debate and critical evidence-based analysis. AAWC education is the best investment of your 2019 CME/CE time and money.

AAWC’s Pressure Ulcer Summit in Atlanta February 8-9 will take a deep dive into the evidence for the treatment of pressure ulcers. There are new confusing and frustrating changes in staging for pressure ulcer treatment. And it is controversial. We will debate it, review the evidence, and discuss alternative approaches. We need your perspective and want your opinion. Join us.

In April AAWC will hold its first Wound Infection Summit examining the problem of bacterial bioburden in chronic wounds. New evidence will challenge long held beliefs on the role of bacteria in healing chronic wounds. We will debate the importance of biofilms, challenge the ability of clinical examination to diagnose infection in chronic wounds. Also, we will take a hard look at diagnostics and discuss antibiotic stewardship for the wound care clinician.

As the 2019 AAWC educational program evolves, there are several more Summits across the country in development. In addition, there are new tracks in collaborating society events such as the Cardiovascular Catheter Therapeutics: Advanced Endovascular and Coronary Intervention Global Summit (C3). The AAWC will host an education track focused on a multidisciplinary approach to wound care issues such as chronic infection, pain management, edema/lymphedema treatment, use of advance wound care products, developing a clinical research program.
These AAWC 2019 educational seminars are the places where passion for our practice expands. We look forward to hearing from you, learning from one another, and sharing our skill set for the advancement of wound care.

My end of the year blogs continue to focus on the accomplishments of our amazing AAWC volunteers. The AAWC’S Healthcare Public Policy Committee (HPPC) faced several challenges this year and the efforts of our volunteers deserves acknowledgement. When CMS proposed reducing Evaluation and Management codes from five to two categories, the change threatened a substantial reduction in physician fees, endangering the specialty of wound care. Collaborating with numerous other societies to defeat the proposal, the HPPC successfully overturned the decision thereby preserving the current payment scheme. In addition, United Healthcare (UHC) issued a problematic coverage policy during the summer limiting choices of cellular and/ or tissue-based products available to clinicians. With cooperation and assistance from the Alliance of Wound Care Stake Holders, the AAWC prepared and submitted comments to UHC to request policy changes. Finally, the HPPC evaluated and responded to numerous CMS coverage determinations and policy proposals.

On behalf of the wound care community, the HPPC remains the watch dog of the AAWC. Our volunteers continuously survey the reimbursement and regulatory landscape, responding rapidly to protect the interest of our members, allowing patients to receive best in class care. The 2018 membership survey identified public policy as one of the top priorities for the AAWC. We listened. The Committee will continue to monitor the ever-changing policies and coverage determinations with the full support of the AAWC.

A special thanks to the current HPPC members: Peggy Dotson, RN BS, Chair, Ali Baros, MD, Kara Couch, MS, CRNP, CWS, CWCN-AP, MS, Gary Gibbons, MD, FACS, Mary Haddow, RN, CWCN, Eric Lullove, DPM and Kathy Schaum, MS.

Que Future Mas Bello

“The future is bright,” to quote  Spanish crooner Pablo Alboran. And so it is, especially for members of the AAWC. In the next series of weekly Presidential addresses, I want to share how the accomplishments of 2018 have set the platform for a successful 2019 and beyond.
 
     Strategic Partnerships: Among the AAWC’s strongest initiatives is the Wound-Care Experts FDA-Clinical Endpoints Project (WEF-CEP). This collaborative project with the Wound Healing Society focuses on clinically relevant endpoints for wound-healing clinical trials. The result is advanced wound care products will have a smoother FDA approval pathway providing cutting edge solutions for our patients.
 
     Influential Leadership: A recently accepted article to be published in Wound Repair and Regeneration entitled “Evidence Supporting Wound Care Endpoints Relevant to Clinical Practice and Patients' Lives. Part 2. Literature Survey” was written by members of the WEF-CEP Committee. The compelling findings enabled Peggy Dotson, Marissa Carter, Vickie Driver and Gary Gibbons to appear before the FDA to discuss the details.
    
    Patient Participation: The WEF-CEP Committee reached out to those beneficiaries of our care to ask patients for their perspective on wound care products. The findings from over 400 patients are currently under review and will be published once available.  As a next step, the committee will recommend up to four scientifically achievable, clinically relevant, & patient-centered wound endpoints to serve as primary wound care outcome to the FDA.

    Your AAWC is engaged, influencing policy, and is being heard by the FDA to advocate for patients and clinicians. These are meritable achievements and a credit to your leadership and membership engagement. These accomplishments are the basis of the AAWC’s commitment to speak as one voice for the wound community.

To learn more about the WEF-CEP Project you may access the November AAWC Journal Club Webinar presented by Drs. Lisa Gould and Vickie Driver on the subject.

President’s Message: The AAWC Launches 2019 Regional Education Series

    The AAWC speaks as the voice for the entire wound healing community. And we also listen to our members. More than 80 percent of members have asked for regional education events with single topic symposia.

    Tired of hearing a sanitized and simplified overview on a topic at conferences, you asked for a deep dive presented by investigators themselves. Coming in 2019 is a second annual Pressure Ulcer Summit, critically analyzing and dissecting evidence for the prevention and treatment of pressure ulcers.

A Spring regional meeting to focus on the problem of bacteria in chronic wounds is planned. Currently called W.I.S.E., Wound Infection Summit and Education, the first conference is scheduled for Atlanta in April. It will focus on the diagnosis and treatment of infection in chronic wounds. Experts will debate the latest research in wound infection. We are convinced that focused meetings such as these enable  thorough examination of topics pertinent to our membership.  

    In addition, the AAWC is bringing the meetings to you and increasing the availability of educational opportunities for everyone. We remain dedicated to our focus of being accessible, connected to our membership and collaborative, drawing on the knowledge of our interprofessional members.

    As we plan for 2019, I am reaching out personally to every member for guidance and assistance. Together we can advance the specialty of “woundology.”

    I look forward to hearing from you: [email protected]

National Pressure Ulcer/Injury Day
Catherine Milne APRN, CWOCN-AP

Why does it seem that everyday has a special name? I’m not talking about “Monday” or “Saturday”. Rather, “National Sunshine Day” or “Hedgehog Recognition Day”. I was happy to discover that Representative Tom Emmer, along with his colleagues Rep. Karen Handel, Bruce Poliquin and Rob Woodall have proposed H. RES. 1133. What is H. Res. 1133? It is the proposal to name every third Thursday of November National Pressure Ulcer/Injury Prevention Day and brings this critical issue to national recognition beyond our daily scope. CLICK HERE to read the letter from Representative Tom Emmer.

The resolution brings awareness that over 2 million Americans are impacted by pressure ulcers/injuries annually. With that, the call to action to focus on research, prevention and early detection. More importantly, H. RES. 1133 encourages the Department of Health and Human Services (HHS) to review current protocols and develop a plan to use peer-reviewed science to test and revise pressure ulcer/injury protocols. Additionally, H. RES. 1133 calls on HHS to host an annual Federal inter-agency conference that includes healthcare providers, community caregivers, patients/families, veteran advocacy groups, academia to publicly review and discuss the state of pressure ulcer/injury research, protocols, scope and magnitude of the problem.

Sounds like a dream come true, right? Well, it IS a dream. We need to make it a reality. H. RES. 1133 is still a proposal and it still needs to pass to become a reality. How can that happen? You...yes, YOU. It’s not as hard as it sounds.Write your Representative and tell them how important it is. I promise you that it will only take 5 minutes. That’s less time than most dressing changes. And this change can change the world.

Here’s how:
Click on this link https://www.contactingcongress.org/
Type in your Zip Code
Find your Representative
Follow the directions to send an email.
Don’t know what to say? I have made it easy for you. Personalized letters weigh more favorably on our Representatives. The AAWC has drafted two letters that you may find helpful to use or amend. The first sample allows some personalization. Please feel free to add any other information you may want. The second sample letter, though less personal, will still have an impact.

Dear Representative (insert their name here),
As a (include your title here…Physician, Nurse Practitioner, Physical Therapist, etc.) who (cares for, manages, frequently sees, etc.) patients with pressure ulcers/injuries, I urge you to support H. Res. 1133 –Pressure Ulcer/Injury Prevention Day. This devastating health problem affects 2 million Americans a year and contributes to the death of 60,000. Pressure ulcers/injuries affect all ages and is seen in all healthcare settings as well as in people being cared for by their loved ones.

Your support of H. Res. 1133 will help countless Americans prevent the pain and suffering associated with pressure ulcers/injuries.

Thank you.

(Sign with your name)
 
Dear Representative (insert their name here),
As a healthcare provider who frequently sees patients with pressure ulcers/injuries, I urge you to support H. Res. 1133 –Pressure Ulcer/Injury Prevention Day. This devastating health problem affects 2 million Americans a year and contributes to the death of 60,000. Pressure ulcers/injuries affect all ages and is seen in all healthcare settings as well as in people being cared for by their loved ones.

Your support of H. Res. 1133 will help countless Americans prevent the pain and suffering associated with pressure ulcers/injuries.

Thank you.

(Sign with your name)

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.

How to Achieve Complete, Accurate Documentation

Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: [email protected]
Twitter: @HogueHomecare


Complete, accurate documentation is paramount in health care!  Practitioners can’t achieve quality of care for their patients without it. Licensure and certification depend upon it.  It’s necessary for payment.  Avoiding possibly devastating results from audit activities by outsiders; including target probe and educate (TPE), RACs, ZPICs, etc.; relies upon complete, accurate documentation.  It’s just plain crucial!  And yet…providers continue to struggle mightily with inadequate documentation that regularly produces adverse results.  How can the problem be addressed effectively?  

Anecdotally, it seems that most providers know how to produce complete, accurate documentation, but they don’t.  Now there is a study that seems to verify that this is indeed the case.  Researchers from the University of Manchester, Columbia University and Appalachian State University worked with the Visiting Nurse Services of New York (VNSNY) to address questions about compliance.  The results of the study appeared in the American Journal of Infection Control on June 14, 2018.

The study revealed that knowledge is not the most important factor with regard to compliance with effective infection control measures.  The nurses in the study certainly knew about and understood standards of care regarding effective infection control.  Rather, the study showed that attitude, as opposed to knowledge and experience, was the key factor to achieving compliance.  The results of this study also seem applicable to compliance with applicable standards for complete, accurate documentation.

When providers identify deficiencies in documentation, it is often tempting to provide additional education to staff about how to document completely and accurately.  The assumption seems to be that practitioners aren’t documenting completely and accurately because they don’t know how to do it.  Instead, it now appears that the issue isn’t knowledge or experience at all.  According to this study, it’s all in the attitude!

Consequently, targeted strategies to alter the attitudes and perceptions of staff members are needed.  When staff members see documentation as the linchpin that it is, they will do a better of completing documentation that is complete and accurate.  How can managers change the attitudes and perceptions of staff members?  

It seems likely that documentation must become personal.  That is, practitioners must have some “skin in the game.”  In other words, the importance of complete, accurate documentation is not avoidance of some distant payment denials or adverse audit results that may impact staff members little, if at all.  The consequences of inadequate documentation must come home to practitioners in order to change attitudes and perceptions.

Managers can likely determine how best to accomplish necessary changes in attitudes and perceptions of their staff members. It may be helpful to individualize strategies for doing so.  Perhaps it’s time to tie compensation extremely closely to the timely preparation of complete, accurate documentation.

In short, less emphasis on reeducation and more emphasis on attitudes and perceptions is needed now!



©2018 Elizabeth E. Hogue, Esq.
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