Quality wound management is a persistent concern for providers, patients, and families across the post-acute and long-term care health care space. As a patient transitions through this continuum, wound management can become fragmented, which contributes to delayed wound healing, prolonged suffering, and increased health care expenditures.
As they maneuver through the various levels of care, patients with complex or chronic wounds need consistent support and guidance to ensure they receive current, evidenced-based treatments and recommendations for their wounds. Consistent oversight is also needed to ensure that wound plans of care appropriately evolve as the wound evolves, despite the location of care.
Challenges in Wound Care
The effectiveness of wound care in PALTC is anchored by four parameters:
- 1.Governmental regulation (and reimbursement)
- 2.Insurance coverage and payments for products, services, and treatments
- 3.Availability (or lack thereof) of clinical expertise and resources in wound care
- 4.Ability of the patient (or their health representative) to advocate for benefits
As an example, consider a patient with a vascular lower extremity wound. Once transferred to a skilled nursing facility, the diagnostic tools needed to quickly assess this patient’s arterial status may be limited due to insufficient clinician knowledge or insufficient SNF reimbursement from Medicare Part A. In addition, access to specialists needed to manage this vascular wound may be limited by logistical factors such as patient transportation to the specialist, health care surrogates’ schedules, or location and availability of the specialist.
Wound treatment formularies also vary among health care settings. Patients discharged from one setting with one type of wound product may not find the same wound product available in the next setting. From setting to setting there also may be varying opinions on the healability of a wound and the appropriate approach to wound treatment.
Depending on the wound expertise of the clinical team, they may or may not be able to navigate between comparable products that produce the same positive wound outcome. Facility resources such as staffing and the ability to keep a well-stocked central supply also influence the approach to wound treatment from setting to setting.
Standardizing Wound Care
One suggestion to improve wound management in PALTC is to standardize the approach to wound care throughout all settings. The Post-Acute Wound & Skin Integrity Council (PAWSIC) is a nonprofit, professional group that advocates for best practices in patient-centered wound care across all settings, including PALTC. Its members come from multiple health care disciplines with expertise in wound care and practice settings across PALTC.
Many wound issues during transitions center around education, communication, and collaboration. PAWSIC has created a reference checklist to assist decision-makers (administrators, program development, or planners), patients and their families, and clinicians with the foundational components for a wound care program in the post-acute space. The PAWSIC Provider Checklist is the first interprofessional collaborative quality improvement document to standardize this highly fragmented area of practice. This checklist could be used to:
- •Provide structure for a new facility wound program.
- •Evaluate an existing wound program.
- •Serve as an evaluation tool for an external company offering to provide a wound program.
- •Provide a reference for patients and their health care advocates.
The main components and a sample of questions from the checklist can be found in the accompanied table. The PAWSIC board acknowledges that this first iteration will likely evolve as its users provide feedback.
Adopting the Checklist
Facilities initially adopting this tool may first opt to incorporate it into their quality assurance process improvement efforts. For example, the tool may be used to evaluate the current program and to identify gaps and create goals for process improvement. As patient-centered interprofessional wound programs are in various stages of development, it is possible that several areas of improvement may surface, and leaders may wonder where to best concentrate their efforts.
PAWSIC would suggest the initial focus should be on team/interprofessional alignment of documentation and effective team communication.
Documentation would encompass education and training to ensure interrater reliability among all facility clinicians evaluating the wound, especially for pressure injury staging. Inconsistences with staging can be a red flag during surveys and litigation and can cause confusion for patients, families, and other clinicians who are providing follow-up care.
In addition, effective communication — verbal and written — minimizes the potential risk of misunderstanding the goals of wound care and levels the set of expectations around wound healability. Effective communication includes the interdisciplinary team providing the same message to patients and their families.
The interdisciplinary perspective is the foundation of this tool by design. Regardless of the many reasons why a facility, a provider group, or a patient advocate may adopt this tool, the ultimate goal is to improve outcomes by shifting wound management from a siloed medical-centric approach to a patient-centered team perspective.
The PAWSIC Wound Provider checklist can be accessed at www.pawsic.org.
The authors would like to thank and acknowledge the contributions of the PAWSIC national board of 19 interprofessional wound care experts who serve as a source and advocate for wound management in post-acute care.
Dr. Bolhack is an internal medicine, and hospice and palliative medicine specialist with additional credentials as a certified wound specialist physician and a certified medical director in long-term care. He has experience as a medical director for skilled nursing homes, assisted living facilities, hospices, home health agencies, and wound centers.
Ms. Maguire is a physical therapist and certified wound specialist with more than 25 years of wound care experience across the continuum of care. She is a member of the ACHA education committee, faculty/speaker for SAWC, and president of the Post Acute Wound and Skin Integrity Council (PAWSIC, 501c6 pending).
Dr. Nalls is a geriatric nurse practitioner with experience in long term care, palliative care, palliative wound care, and hospice. She also is adjunct faculty at University of Maryland School of Nursing.