19234 Wallingford Avenue North
Shoreline, WA 98133
Phone: 206 542 0748
Fax: 206 542 2870
Email: pacific.telemedicine@verizon.net
Wound Care Fact Sheet for Home Health and Long Term Care
Introduction
The need for education in wound care is urgent in both the Home Health and Long Term
Care arenas. The following information clarifies this need.
Background – Wound Care
? Wound care has undergone intensive medical/scientific research over the past 20
years. As a result, care techniques and products have been evolving rapidly.
? There are currently over 2000 wound care products on the market, none of which
were available 15 years ago. In addition, there are many new techniques, making
wound care complex.
? It is estimated that 10% or less of practicing doctors and nurses have kept pace with
the changes in wound care.
? In modern wound care, there is no single “right way” to treat wounds. Healing is now
known to be a dynamic process and treatment varies according to conditions present
in each wound.
? Modern wound care has been shown conclusively to heal wounds quickly, with less
chance of infection and greater patient comfort, all at reduced cost. Its only downside
is the increased complexity and the consequent requirement for education of
doctors and nurses in order to practice competently.
? Reality is that the most commonly used wound dressing technique, used across the
whole of the United States today, is wet-to-dry saline and gauze, a technique that
originated in the 1800s. Research has shown conclusively that this dressing
technique impairs wound healing, increases patient pain and discomfort, increases
chances of infection and costs more than most modern dressing techniques.
? In 1993, the Federal government issued a Clinical Practice Guideline (refer to
AHCPR Publication No. 95-0654, Clinical Practice Guideline Number 15) in an
effort to remedy the acute need for change in wound care practice. Today, ten years
later, few home health or long term care facilities have been able to implement those
guidelines due to insufficient staff education in modern wound care.
Impact of poor wound care on Home Health
? Modern wound care costs substantially less than the traditional saline and gauze
technique.
? Medicare only reimburses home health at a level required to perform modern wound
care consistent with the Federal Guidelines.
? Wound care is typically 25-30% of the home health case load.
? Typical Medicare reimbursement for a patient with a chronic wound is $350 per week.
One home health nurse visit costs on average $110.
? Wet-to-dry saline and gauze typically requires daily or twice daily dressing changes
i.e. between 7 and 14 home health nurse visits per week. The cost, in nurse time
alone, is between $770 and $1540. Wound care product cost is additional. With
expected reimbursement at only $350, this represents enormous loss to the home
health agency. Over the course of the wound healing (on average 16 weeks), the
home health agency would have a deficit of between $9520 and $21,840 per patient.
? Modern wound care dressings typically require two to three dressing changes per
week i.e. 2-3 visits per week.
? At 2-3 visits per week, the cost is $220-$330 plus product cost. With expected
reimbursement of $350 per week, the agency will be within budget, with occasionally
a few dollars left over to cover contingencies.
? Due to the tight budget and complexity of modern wound care, it is essential that staff
are well educated. Staff attempting to practice modern wound care with insufficient
education make poor technique and product choices, costing agencies not only in
products but also increasing the time to heal, reducing patient satisfaction and raising
the risk of survey problems.
? Financially, clinically and ethically, it is imperative that home health agencies
practice modern wound care but few have the educated staff to do so.
Impact of poor wound care on Long Term Care
? State and Federal regulators mandate that poor wound care is sufficient grounds to
close any long term care facility.
? Medicare does not reimburse for any pressure ulcer (the most common type of
chronic wound) developed in-house other than Stage 1. Without reimbursement,
facilities have to carry the full cost of care.
? Medicare considers the above-mentioned wounds as caused by neglect and their
presence is grounds for citation resulting in “stop-placement” (no further patients can
be accepted until identified problems are remedied). This kind of citation has serious
consequences financially and in public reputation.
? Federal and state surveyors perform annual surveys of care practices but they can also
come, unannounced at any time. The care practices of any chronic wound can be
cause of citation.
? Wound care is one of the two top reasons for long term care facilities to face medical
litigation.
? As in home health, poor product choices cost money in both product cost and healing
time.
? Margins are so tight in long term care that all facilities are forced to keep staffing as
low as possible while still maintaining the quality of care required. Registered nurses
must perform skilled wound care but their time is at a premium. Modern wound care
requiring 2-3 dressing changes per week are an obvious time and cost saver compared
to saline and gauze dressings which are done up to 4 times a day (28 times per week)
in the long term care setting.
? In long term care, the greatest imperative is a wound prevention program of high
quality. Without knowledge of modern wound care, it is very difficult to develop an
effective prevention program. At-risk patients must be identified on admission and
assessed regularly for any deterioration or symptoms of wound development.
Without a prevention program, facilities run the risk of poor surveys and litigation, as
well as lost staff time, losses on product cost, increased patient suffering, all leading
to budget strain and loss of reputation.
? Staff turnover is very high in long term care facilities. Staff education is an issue that
never goes away. It is a constant, pressured struggle to find the funds to meet the
levels of education required just to keep the doors of the facility open.
In light of the above facts, it is clear that education in wound care is essential to the
survival of every home health and long term care facility. Wound care specialists
are in high demand but short supply. Education programs designed for doctors and
general nurses are rare. There is a specialty program at the University of
Washington for Wound Care Certification but this can in no way meet the need
state-wide to raise knowledge levels of all nurses in all health arenas. This problem
needs urgent attention.
Wound Care Excellence that is Accessible and Affordable Pacific Telemedicine is comprised of a network of expert, independent wound care
specialists. Because we are a network, there is always an expert available to provide
consultation in any location. We are affordable because our fees are stepped to ensure
you only pay for the time and type of service you need without the overheads related to
staff members, travel costs, etc. We provide the most cost-effective wound care available
today.
All our programs are designed to provide the best possible outcomes at the lowest
possible cost in time and money. Telemedicine technology is the tool that makes this
possible.
Telemedicine
Telemedicine technology, defined as distance delivery of expert medical advice via
telecommunication technology, facilitates effective management of wound care. This is a
critical issue for every care provider today. The deleterious effects of poor survey results, inefficient use of staff time and dissatisfied patients are all too familiar. Telemedicine
has a proven track record with wound care. We are absolutely certain that the advanced
techniques used by our experts will heal wounds faster, with less patient discomfort and
disability, than traditional methods of care.
Consultation
Pacific Telemedicine connects wound care experts with clinicians in real time, facilitating
consultation that can provide:
? Clinical wound assessment
? Prevention assessment (based on the Braden Scale)
? Excellent documentation, including wound images
? Weekly, monthly or quarterly tracking and reporting of care and outcomes ? Education using our innovative and effective Invisible Education Program
Equipment
The telemedicine equipment is easy to use and requires only a telephone line. There are
several equipment options and we select what suits the needs of the patient, the wound
and the facility best.
Services Provided
To provide excellence in wound care, Pacific Telemedicine offers a raft of service
options. Healthcare providers are able to select what they need and we tailor the service
to achieve their desired goals. We offer:
? Expert wound care consultation, on an as-needed basis, via telemedicine technology,
making it more cost-effective than full time, part time or contract employment of
experts
? Set-up of telemedicine infrastructure for use by your experts or ours ? Comprehensive, facility-wide assessment of clinical, financial and administrative
factors of wound care, culminating in a performance improvement plan ? Implementation of performance improvement plans
? Education in advanced wound care technique
? On-going, outcome based, quality improvement planning.
Financial Impact
Wound care must be patient-centered first and foremost but it also must make financial
sense. We have seen, all too often, facilities burdened with unnecessary wound care cost
in both time and dollars. Areas where we can make a significant financial impact are:
? Maximizing reimbursement levels
? Minimizing cost on expert consultation
? Eliminating expensive “clean-up” efforts from poor survey results
? Minimizing risk of litigation with excellent documentation and best-available care
? Ensuring product selection and use is cost-effective
? Tracking wound care so wounds don’t get “lost” in the system and become hidden
costs
? Tracking outcomes to ensure problems are identified and resolved quickly ? Making wound care efficient by using advanced technique, thus cutting nurse and
doctor time input significantly
We Meet Your Needs
Because we tailor our service to meet the needs of the facility, we can provide as little as
individual patient consultations or we can expand to provide full, facility-wide programs.
In all cases, the aim is the same: to provide excellent results with the best financial
margins.
Please contact us if you would like more information on our services and how we provide
them.
Pacific Telemedicine
19234 Wallingford Ave N, Shoreline, WA 98133
Phone: 206 542 0748 Fax: 206 542 2870
Email: pacific.telemedicine@verizon.net
OVERVIEW of the
INVISIBLE EDUCATION PROGRAM
Teaching Methods, Strategies, Materials and Resources
The Invisible Education Program (IEP) is very unique and differs from normal in-service
education programs. Therefore, the following is an overview that explains how this
program is different and how it intends to achieve its educational aims and objectives.
The program is called “Invisible” because knowledge is delivered in very small
“nuggets”, in the care environment rather than in a classroom environment. Nurses learn
about wound care while they consult with an expert on care for their patients. The
learning is worked seamlessly into their patient care routines in such a way that it hardly
seems to be there at all; it is virtually invisible.
Advanced wound care is a complex and difficult subject. Our experience with standard,
passive education on this subject is that most of it slips away from the learners mind with
barely a trace left behind. This experience prompted us to develop a program that really
gets through and is retained. Four educational techniques are employed:
1. Just-in-Time-Information - Our experts educate during wound care
consultations, intermingling education with hands on case review; knowledge is
given at the time it is used, making it completely relevant and significant.
Knowledge is given in small, meaningful nuggets of roughly 5 minutes duration
so the learner is not overwhelmed with detail.
2. Knowledge Sharing – We work with our clients (healthcare providers) to set up
opportunities for nurses to share what they are learning with their colleagues. To
teach what they know to someone else is one of the best ways to cement their
understanding, as well as “spread the word.” This also improves the cost-
effectiveness of the program. For example, the nurse could be given a 5-minute
slot in a weekly team meeting to share one “nugget” that she gained that week
with the team such as how enzymatic debridement is being used for her patient
with a pressure ulcer.
3. Knowledge Feedback Cycle – Our experts track the information they have given
the nurses and look for an opportunity to have the nurse retell that information
back to them under relevant circumstances. For example, while discussing a
pressure ulcer with the nurse, the expert may ask, “Can you remember our reasons
for using enzymatic debridement last week?” The response validates that the
learning has taken place and provides the opportunity to reinforce it again. The
teacher and the learner both keep track of what topics have been covered and what
topics the learner has successfully demonstrated later. The program is completed
when all topics have been covered and successfully demonstrated. Refer to the
“Wound Care Bingo” Education Tracking Chart from the Clinician Workbook. In
the event that no patient with a wound of a type covered in the program is present
in the facility, a patient with the underlying disease process can be identified and
considered from a wound prevention perspective. This is an extremely valuable
perspective for all nurses to gain.
4. Self-guided Reference Building – During our program, the nurses build their
own workbook with study materials we provide, digital images of wounds they
know, their own notes and ideas, product samples they collect and reference
material they choose to gather. This workbook becomes a long-term reference for
them as well as a trigger for any knowledge they may not employ everyday.
The important point of these techniques is that the nurse is directly interactive with each
piece. All knowledge is used, handled, manipulated and retold so it is never passive.
The Invisible Education Program has 4 modules:
1. Moist Wound Healing
2. Wound Assessment
3. Wound Diagnosis
4. Product Selection
We consider these the core areas for baseline competency in advanced wound care.
Telemedicine Delivery
Invisible Education is unique in another way. It has been designed to be delivered via
telemedicine communication. The number of available wound care experts to teach this
valuable program is far below the number needed to physically travel to all the
communities and healthcare providers who need wound care education. However, using
telemedicine technology, those same experts can reach any community on the globe.
Location ceases to be an issue. This program has been designed to be delivered over the
phone or the internet, depending on the technology available at a given site. One live person contact is made initially to introduce the program and familiarize learners with how it all works. That person does not need to be a wound care expert. From that point forward, the experts take over and have weekly, bi-weekly or otherwise-scheduled consultation and education teleconferences. The learners take digital images of their wounds and fill in a standardized assessment form. The image and assessment are transmitted electronically to the expert and become the starting point for each consultation/education session. This program can be delivered equally well in circumstances where there is a resident wound care expert. The same educational techniques would be used but in-person consultation/education sessions would replace the electronic ones.
Kim Adams, the designer and initiator of this program, has been involved in telemedicine wound care and education for 3 years and has seen the positive impact of this method. However, this is the first time that the education has been developed into a formal program with workbooks, guidelines and tracking.
We expect the program to take roughly 2 months for each nurse. However, we would like the option to extend it in order to cater for the varying motivation and learning ability of the nurses. Because the education is combined with consultation, it does not represent a financial burden to the facility to pay for this length of time. In fact, it is highly cost effective because they literally get “2 for the price of 1” i.e. education mixed in with consultation at no extra cost. The purpose of this open timeframe is to get away from the problem of giving nurses information that they can’t use at the time. Information that
isn’t used is lost and represents a waste of everyone’s time and energy. The information given in this system is used immediately, lending it relevance to each learner.
One of the ways that the IEP can accelerate the program, if needed, is through small group teleconferencing. For instance, if there were 3 patients in a facility with wounds and one was a diabetic, one had venous stasis and one had a pressure ulcer, we can work with 3 nurses caring for those patients as a small group. The case review and consultation can be shared so all learn about the others’ cases. All 3 nurses can get the hands-on exposure to relevant information and progress quickly through the required topics.
It is important to note here that Pacific Telemedicine has taken great care that the privacy and security of patient information is fully protected at every point. All components of this training comply with current HIPAA standards.
Teaching Materials
The Clinicians Workbook is a carefully constructed compendium of learning materials that support and augment the verbal teaching by the experts. Its contents are discussed in detail below.
Section 1 – Moist Healing
? Colorful Illustrations and Bulleted Key Points - This supplement to the
first day overview is an easily accessible reminder of the learning points
covered. It also provides references for those who wish to take their
learning a step further.
Section 2 – Diagnosis
? Plastic Sleeves for Wound Images – These allow nurses to collect and
retain images of wounds. These personal reminders from patients/wounds
they have known are far more powerful than images from unknown
patients, as found in most textbooks and guides.
? Laminated Diagnostic Checklists – These are re-usable with dry erase
pens. For future reference, the nurse can use these charts for any wound to
help her distinguish wound type.
Section 3 – Assessment
? Wound Assessment and Companion – A standardized wound assessment
tool* is paired with a “Companion” that explains key points of the
assessment. Each nurse will use the standardized wound assessment tool
on a weekly basis to document her patient’s wounds. The Companion
gives depth of understanding, making the assessment a far more
meaningful tool. The points covered in the Companion will also be
covered by the expert in the consultations. Thus, the Companion
reinforces topics covered in the program.
? ABI Calculation Sheet – A laminated, reusable tool for calculating an
Ankle-Brachial Index. This Sheet walks the nurse through the calculation
as well as provides a reference to interpretation of scores.
Section 4 – Products
? Product “Cards” - these are used to staple in product samples as reminders
and for future reference. The nurses collect these samples as they use
them in patient care, making notes on the cards of how and why the
product was used. Further product information (e.g. leaflets) can be glued
on the back, keeping it handy for future reference. Note: Invisible
Education and Pacific Telemedicine do not support or advertise any
particular brand of product. The program teaches generic product type
and refers nurses to the products nominated in their facility product
formulary.
? Fill in Formulary Blanks – the product functionality sheets have fill-in-
the-blank spaces for nurses to find out and fill in their facilities product
formulary for each functional area. This is an active learning activity that
ties product function with the name and storage location of the products
that will be used most often.
Section 5 – Learning Tools
? Knowledge Assessment Test – used as both a pre- and post-test.
? Wound Care Bingo Card – education tracking tool to ensure all topics are
both covered and reverse demonstrated. These also serve as a reporting
tool to nursing management to show progress through the program.
? Wound Care Tracking Charts – individual nurse and whole facility
versions. These are made available to all facilities in electronic form
because Pacific Telemedicine recognizes that an effective wound care
program within any healthcare facility should include tracking of wound
care so that care can be easily overseen and monitored for weakness and
improvement. Personal and facility-wide changes in care provide
powerful learning feedback.
? Circular Wound Measurement Tool – this clear plastic, reusable
measuring tool assists the nurse to assess change in a wound with
consistency. Consistency of measurement is a very important factor in
gauging improvement or degeneration of wounds.
*We use the Bates-Jensen Wound Assessment Tool, by permission from Barbara Bates
Jensen.
Invisible Education - Management Perspective
Pacific Telemedicine’s education program is unique, as is reflected in its name
“Invisible”. We utilize a number of educational techniques that are known to be highly
effective but very different from the traditional classroom style of learning. The
education appears invisible. It is delivered slowly, in small segments, as the nurse works
so that it works seamlessly with actual clinical practice. Our experience with traditional
in-service education is that most of it “goes in one ear and out the other,” and that
passively learned knowledge often slips away without a trace. This experience led us to
employ our unique approach. Our program uses 4 techniques that provide an education
that really sticks:
1. Just in Time Information – Our experts educate during wound care
consultations, intermingling education with hands on case review; knowledge
is given at the time it is used, making it completely relevant and significant.
2. Knowledge Sharing – We work with you to set up opportunities for nurses to
share what they are learning with their colleagues. To teach what they know to
someone else is one of the best ways to cement their understanding, as well as
“spread the word”. This also improves the cost-effectiveness of the program.
3. Knowledge Feedback Cycle – Our experts track the information they have
given the nurses and look for an opportunity to have the nurse re-tell that
information back to them under relevant circumstances. This validates that
the learning has taken place and provides the opportunity to reinforce it again.
4. Self-guided Reference Building – During our program, the nurses build their
own workbook with study materials we provide, with digital images of
wounds they know, with their own notes and ideas and with reference material
they choose to gather. This workbook becomes a long-term reference for
them as well as a trigger for any knowledge they may not employ everyday.
The important point of these techniques is that the nurse is directly interactive with each
piece. All knowledge is used, handled, manipulated and retold so it is never passive.
The Invisible Education Program has 4 modules:
5. Moist Wound Healing
6. Wound Assessment
7. Wound Diagnosis
8. Product Selection
Our experts work through the curriculum, but deliver each module as it becomes relevant
to patient care, meanwhile tracking the nurses’ progress so that regular reports of that
progress can be shared with the nurses and supervisors.
The Invisible Education Program provides 9.3 Contact Hours for Continuing Education
Credit from the Washington State Nurses Association. The American Nurses
Credentialing Center’s Commission on Accreditation backs all WSNA credits so that
they are nationally recognized.
Each module covers the essential topics that will give the nurses the knowledge they need
to not only treat the wounds in their care with understanding, but also arm them with the
knowledge they need to fill in Medicare documentation accurately, seek timely advice if
their wounds fail to progress and select products and procedures that are truly cost-
effective.
We expect providers to gain many advantages from this program, in addition to the
improvement of staff knowledge and performance. They include:
? Increased patient satisfaction, due to faster healing and greater comfort
? Better reimbursement from Medicare, due to more accurate diagnosis
? Significant savings on modern products from better selection and usage
? Huge savings from elimination of saline and gauze dressings
(remember, saline and gauze dressings are the most expensive and least
effective dressing technique in use today)
? Reduced need for traditional in-service education on wound care
? Improved accreditation review results regarding wound care
Pacific Telemedicine
19234 Wallingford Ave N, Shoreline, WA 98133
Phone: 206 542 0748 Fax: 206 542 2870
Email: pacific.telemedicine@verizon.net