This blog captures the conversation Home Health Revealed had with Katherine Piette and Alicia Jenkins from Corstrata. In this blog, we discuss a topic in home health that has become a $40 billion problem: wound care.
Alicia serves as Corstrata’s Clinical Director for Provider Services; she has over 20 years of experience as a wound consultant and leader in home health, hospice, and other post acute settings. She has a deep perspective on the opportunities for post-acute providers with wound and ostomy patients, and specifically with virtual wound management.
Katherin Piette is CEO and co-founder of Corstrata, a specialized tele-health services company, offering virtual access to certified wound and ostomy specialists. She has experience with patient outcomes, lowering costs, and has 20 plus years of post acute healthcare experience as an executive. She has served in marketing and operational roles. She brings extensive experience in telehealth and process improvement. She co-founded the company in 2015.
Corstrata, like HealthRev Partners, is tech-enabled and they have a pretty impressive free app.
What problems are you seeing and why is it important for agencies to look at their wound care program?
We know there is a problem as there are very few wound and ostomy nurses in the country. In fact, there's only 15,000 of them nationwide and 90% of these practice in the acute space. So there's a true lack of access to wound experts to really help drive and improve treatment plans and the financial and clinical outcomes associated with wound patients.
How big of a problem is wound care?
Alicia: I became wound certified back in ‘98 and have practiced wound care since then, and it has been an exciting journey and certainly lots of change from doing paper charting to electronic charting and now to telehealth. The wound care problem is huge for multiple reasons. There is a lack of knowledge regarding wounds and how to address them and take care of them. Wounds are seen across all floors of a hospital and across all diagnoses. Patients with multiple diagnoses can have a wound, but it doesn't mean that they're secondary; it’s a big issue that should be treated as a primary need for that patient. Frequently, you see patients come out of the hospital after a lengthy stay with a wound that is hard to heal.
It's a challenge for them because it's painful, it's odorous, and it takes time to heal. On average 30% of the patient population in home health has a wound and we've seen agencies where that number is even 40% to 50% of their patient population.
It’s important to have the knowledge level to care for that large patient population. From a home health perspective, here’s why:
1) It isn’t in the patient's best interest as the goal is to get them back to independence and living freely. They’re still suffering if they have a wound that's not being treated properly. If you are able to treat a wound properly, it gets the patient on that path to healing.
2) It affects the home health agency’s staffing costs. I have seen agencies with high utilization of skilled nursing to treat wounds because they’re not confident in the type of wound and don't have a good treatment plan in place. Frequently, you'll see skilled nurses being utilized at a higher rate if you don’t have a good plan and treatment regimen in place or knowledge based around the appropriate treatment for different etiology of wounds.
3) It also affects supply costs. Sometimes there are advanced wound care products, but staff are not comfortable with utilizing them as recommended. We’ll still see orders for daily dressing changes. And sometimes, it may be the caregivers who are performing daily dressing changes. Both drive high supply and staff utilization. This isn’t in the patient's best interest and certainly isn’t in the agency's best interest because of the high cost.
4) It affects quality reporting. In home health and hospice, 30% of the time we see wounds misidentified in terms of etiology. If you haven't identified the appropriate etiology of that wound, you're not going to have an evidence-based treatment plan. Additionally, we found that 50% of pressure injuries are not staged appropriately. Again, this has downstream effects for both the proper treatment, as well as for quality care and reporting.
As a home health agency, what are the key components to having a successful wound care program?
There are six core areas or core components of a home health wound care program that’s successful.
- Make sure your agency has comprehensive home health wound care policy and procedures. These need to be established and reviewed on an annual basis because many things change in terms of evidence-based practice, etc.
- Be sure that your treatments are evidence-based and that you're using the latest recommendations. With pressure injuries, a lot of work has come out in the past few years showing changes to best practices. These changes must be incorporated into your care plan.
- Have a standardized formulary. You must have advanced wound care products in your formulary that will allow for evidence-based care treatments to be provided.
- You want to make sure that you know your formulary and the unit cost so you’re effectively managing costs with that formulary.
- Having access to board certified specialists for etiology identification for pressure injury staging, for an evidence-based care plan, and for ongoing evaluation of staff competencies are key as well.
- Clinicians need to understand negative pressure and negative therapy devices and how to apply compression appropriately. Agencies must establish key performance indicators in order to drive both clinical and financial outcomes associated with wounds because they’re high utilizers of your resources.
What’s a good protocol for home health wound care?
A good first step in your protocol should begin with optimizing the initial start of care. It’s very important that the etiology be identified for the wound. Then it needs to be coded appropriately for the proper billing reimbursement.
It's very important that you get that initial care plan and the initial wound products delivered to the patient and that you get the treatment plan established.
Part of that is having access to experts, whether they are in-house board certified nurses or whether they are outsourced.
How can technology support a wound care program?
The Technology is an enabler for access to board certified wound care nurses. Corstrata has spent time building this new app. It allows a clinician, at the bedside, to take a photo of a wound, then auto measures the wound length and width and calculates the area. It analyzes the tissue and then performs a wound assessment. At that juncture, our wound care nurse is alerted. Then, our wound care nurse looks at the wound imaging and makes recommendations. Recommendations cover the etiology, an evidence-based care treatment, formulary wound products, frequency for visits, associated prevention measures such as pressure injury prevention, and any other additional recommendations. They complete all of that. They also utilize information about pain so we know if we need to adjust the wound care based on pain, especially for more of your hospice type patients or palliative wounds. Other measures include drainage, odor, and all those assessment parameters that a nurse is looking at to evaluate the wound. That nurse can collaborate with them as needed, so any additional information or clarification can give them everything they need to adjust staging as appropriate. They create a wound treatment and everything else that needs to be addressed like nutrition and patient education. It gives them everything they need to support the patient in their own healing journey.
How does partnering with a wound care expert really benefit a home health agency?
Home care agencies have an opportunity to develop and align themselves with resources and build relationships with wound care experts. Home health agencies should know their industry and the importance of these new models.
Home Health Wound Care Documentation
Why is the identification of the wound type and staging so critical for documentation?
The bedside clinician needs accurate identification of the wound etiology both for an effective treatment plan first and foremost, and then to accurately document an individualized patient plan of care.
This certainly affects proper reimbursement and publicly reported outcomes. Not only does a wound need to be identified, but the severity of a wound must also be identified. The severity should be tracked for improvement.
It can be common to see pressure injuries misstaged. For example a stage two could be documented when it's actually a stage 3. This not only affects treatment, but it will certainly affect reported outcomes.
We also frequently see deep tissue injuries documented as stage ones and the expected outcome of those is vastly different. A stage 1 is resolved fairly quickly, as long as pressure is removed. Deep tissue injuries typically evolve into a stage 3 or 4. So, it’s very important that those are identified correctly at the start of care.
How is wound care OASIS documentation, coding, and reimbursement affected by staging?
Identification and reimbursement are directly tied to OASIS documentation and coding. There’s money at stake if this isn't done correctly. So staging and correctly identifying the etiology are crucial for showing improved outcomes. It must be documented and correctly coded at the start of care.
What are the differences in the stages of the wounds?
The stages have to do with the level of severity of a wound. Those are developed by the NPIAP or the National Pressure Injury Advisory Panel. This is how a nurse or clinician identifies the level of injury.
Stage 1 is just your red, non blanchable erythema. Note that it can be harder to diagnose or assess in people with darker pigmented skin, so you have to look for other things too. Questions can be asked of the patient like, “is that area more painful?” Also consider if it feels more firm or soft, or warm or cool, compared to the adjacent tissues.
Stage 2 is a shallow open ulcer. It may just be a moist red or pink wound bed, or it can actually be an intact, clear fluid-filled blister, but it is a partial thickness loss of dermis.
Stage 3 shows full thickness tissue loss, but no muscle tendon or bone is showing. There may be some slough in it. If there is an inability to determine full wound depth because of the amount of slough, then it would be considered unstageable at that time.
Stage 4 is full thickness tissue loss with possible visible or palpable bone, tendon, or muscle loss.
How can agencies reduce face-to-face nursing visits?
Starting with the appropriate wound care and treatment recommendations, right from the start of care, will decrease healing time. If getting good orders or recommendations is delayed, the appropriate care is also being delayed. Getting a patient on the path to healing is going to decrease the amount of time towards healing and alter the length of service. Establishing the adequate visit frequency and getting started with advanced wound care management can support the healing of the body and lessen those face to face visits. Access to a board certified wound specialist at the start of care and at appropriate points along the episode to ensure appropriate treatment can also decrease your face to face visits. For example, let’s say a wound had a large amount of drainage initially and the dressing that we were using before was for absorbency and it is not sticking and drying out. We need to make different recommendations for healing. If the wound is identified as being in deterioration, that needs to be promptly identified and then intervention started. Face to face frequencies can be affected by that timeliness of care.
What is another way we can support our patients as they heal?
Patients must also be educated and understand their own role in the healing process. A patient plays a large part in their healing bycomplying with treatment. Wound care education for staff helps as educated nurses educate patients. We want those patients to become independent.
At times, we have seen patients who are not being compliant with their treatment regimen. Oftentimes, it’s just a matter of that patient understanding how important their role is and their willingness to follow the process.
What educational trends are you seeing in care delivery?
We are starting to see many new trends that are partially a by-product of COVID. So first, we saw a push towards telehealth. I think now we are seeing trends within home health agencies. Initially we saw resistance with face-to-face visits in the early days of COVID.
There are new programs that are evolving and we call those at home delivery models. There’s advanced illness at home and much of what we are seeing are push programs where they are pushing people out of the hospital earlier or out of the skilled nursing facility earlier.
To best support these patients coming home from care settings who are very vulnerable for either having wounds or pressure injuries, wound care is going to be an incredibly needed aspect. Home health has an opportunity to be a resource for some of these programs because they have been doing care at home for many years.
What drew you to start your own company?
Katherine: My co-founder and I came out of the home health and hospice space where we were working in an organization that was a very early adopter of remote patient monitoring. That was even when you had to plug it into the telephone line, so we're talking many years ago but we embraced remote patient telemonitoring.
We were really able to provide a return on investment to the agency by being able to target when to see those patients based on daily monitoring of their vital signs. We wanted to take those learnings of where technology could be applied to a service and really provide access to care in the home.
As members of the leadership team in home health and hospice, my co-founder and I noticed that we were in for a large problem within the home health and post-acute sector. Wounds are not a medical specialty, but they are respected in post-acute as high utilizers of both time and resources in terms of the way we supply.
Where can an agency get additional information about Corstrata?