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Thursday, April 26, 2018Presented at:

Larry Rose RN, BSN, CWON, CFCN

THANK YOU!!!!

To All Our

Home Health Workers!

1. Identify critical issues in overcoming factors that delay wound healing.

2. Discuss and review various types of wound dressings.

3. Describe alternative methods in managing stubborn wounds.

4. Understand precautions of NPWT and safety.

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WOUND- represents a disruption in the normal structure, function of the skin and

d l i ft ti It b l t d underlying soft tissues. It can be related to a variety of etiologies ( e.g. trauma, surgery, sustained pressure, vascular disease, arterial disease, diabetes, and infection)

WOUND CARE - helping the body progress through the 3-stages of wound

i ( f i if ihealing (Inflammation, Proliferation, Maturation) by providing oxygen, nutrients, elimination of non-viable tissue, bioburden control, providing appropriate dressing.

BIOBURDEN - Number of micro-organisms that are contaminating the wound. that are contaminating the wound. Development of a biofilm.

• 200 species of flora on the human skin.

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BIOFILMS - are characterized by an exopolymeric matrix of polysaccharides exopolymeric matrix of polysaccharides, proteins and DNA synthesized by the multiple species of bacteria and fungi present in the wound.

CHRONIC WOUND - is a wound that does not heal in an orderly set of stages over a

i d f tiperiod of time.

• Is there any time frame or can we use a certain period? Example: 3 months

What is a normal healing process?What is a normal healing process?

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Normal Process Of Wound Healing

Fibroblasts, epithelial and endothelial

cells attracted into the wound

Neutrophils and

macrophage attracted into

the wound

Pl l

Neutrophils and macrophages Fibroblasts, Fibroblasts

Injury Mature scar

Inflammatory phase

3 – 4 days

Proliferative and repair

phase 7 -10 days

Maturation and remodeling

phase month - years

Platelets release growth factors and cytokines

engulf bacteria, release growth factors, cytokines and protease

,epithelial and endothelial cellsproduce growthfactors

Synthesis of ECM and new capillaries

orchestrate the remodeling and maturation of the scar

Injury Mature Scar

Age Chronic Disease Perfusion Immunosuppression Impaired Skin Impaired Skin Mental Status Nutrition / Dehydration Edema / Vascular Disease Infection Chemotherapy SCALE - KTU

Medications Medications

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• 50% of Americans take one Rx / month

• 20% take 3 or more / month

• 11% take 5 Rx / month

• 36 Million use herbals yearly

• Anticoagulants

• Antimicrobials

• Aspirin/ NSAIDs; weaken wound contraction with long-term

use (Guo et al, 2010)

• Povidone/ Iodine

• Colchicine

• Dakin’s Soln.

• Glucocorticoids

• Immunopressive agents

• Antineoplastic agents • Colchicine • Dakin’s Soln. • Vasoconstrictors

A ti h t id t• Anti-rheumatoid agents• Nicotine• Chemotherapy• Steroids• NSAIDs• Warfarin- Necrosis

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Notorious inhibitors of wound healing

Notorious systemic effects(hypoglycemia, osteo, mood

changer)

Affect gene expression in cells (all phases of healing)g p ( p g)

Effect is related to the potency of steroid

Long-term use is immune modulator + associated risk

Delay neutrophil and macrophage activity

May result in thinned epidermis (wound contraction)

Topically may help healing

• Wound Cleansing

• Topicals

• Dressings

• Alternative Treatments

Irrigation Normal Saline, wound cleaning solutions

Scrubbing - gauze, micro-fiber pads

Pressurized devices (4 - 15 psi.)

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Antimicrobials

Antifungals

Antiseptics

Enzymatic- collagenase, proteases

Hydrogels

Collagens

Extracellular matrix

Human derivatives

Hydrocolloid

Gauze, ABD

Foams

Composite

Alginates

Wound Fillers

Three categories: Gauze, Foam, Composite

Solution: NS

Method: Each dressing was placed on a flat g p

tray, NS was added over 15 minutes, in 15 ml

volumes. Volume used up to 200 ml

Time-frame after addition of fluid was 30

minutes

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After waiting period, a 180 degree twist was done to each dressingwas done to each dressing.

Which one retained the most fluid?

Factors to Consider:

1. Is the antimicrobial affective against the

infection?

2. How long will it be effective?

3. With excess drainage, will there be

dilution of the antimicrobial?

4. Combination of dyes

WOCN Society

C lt t 360Consultant 360

Medscape

Wound Source (publication)

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Low Frequency Ultrasound via NS Mist

Sound Waves

VOODOO

Vacuum Assisted Closure

It has come a long way to current devices

Vacuum assisted closure is documented in Roman

times, 1500 B.C.

People that were thought to have healing powers would

orall s ck fl ids from the o nds (H man leaches)orally suck fluids from the wounds. (Human leaches)

Cupping Glasses replaced the oral technique.

20th Century negative pressure technique was

developed by the Russians (Dr. Nail Bagaoutdinow)

1990’s work was completed by Dr. Argenta, Wake

Forrest

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Is it appropriate for the patient and the wound?

Have we looked at everything else?

Can it be applied and monitored correctly?Can it be applied and monitored correctly?

Do you have the correct order- mmHG,

continuous-intermittent

Frequency of dressing change.

Exposes the body to 100% oxygen at a

pressure that is greater than what you

normally experience

Delivered by a chamber or gas mask.

Adequate circulation is needed. Determined

by Trans Cutaneous Measurement (t-com)

Delayed radiation injuries

Soft tissue infections

Thermal burns

Certain skin grafts and flaps

Crush injuries

Diabetes related wounds

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Pressure-related injuries to the ears or nose

Nearsightedness (usually resolves)

Non-life threatening convulsions related to Non-life threatening convulsions related to

oxygen toxicity

Decompression sickness

Severe CHF

Claustrophobic

Cost can vary with different markets and

different types of wounds.

Diabetic wounds are usually more Diabetic wounds are usually more

expensive due to possibility of

amputation of one or more limbs.

Thursday, April 26, 2018Presented at:

Trish CarcopaCorporate Health Strategist

Allied Health Occupations EducatorBA Health Management

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SNAPSHOT

• It has been estimated that a single diabetic ulcer carries a cost of nearly $50,000 U.S. dollars.

• Chronic wounds as a whole cost the medical system over $25 BILLION per year with a number of patients affected growing yearly from 6.5 million and given the increasing prevalence of diabetes and other chronic diseases, we can see the impact coming.

• The market for wound care is exceeding $15 billion and treatment for wound scarring is another $12 billion in the U.S. (Stats per NIH).

DOCUMENTATION

• It has been said that, connecting the information to make the claim for reimbursement starts with the physician and clinician.

Very few providers can boast a zero claim rate. Health care providers face challenges with implementing effective claim denial management

Th l i d i l t th process. The average claim denial rate across the healthcare industry is between 5% and 10%.

Providers should keep their claim denial rate towards the 5% to ensure that their organization is maximizing claim reimbursement revenue.

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Claim denial rates at 5% are not easy…Let’s take a look at some of the BIG INSURANCE COMPANIES:

1. ANTHEM had highest claim denial line with 2.64%

2. HUMANA with 1.97%

3. AETNA with 1.5%

4. CIGNA with 0.54%

On the other hand, public payers tended to send more claim denials. Medicare’s report card showed 4.92% of claims were denied.

A serious lack of standardization in the health insurance industry, different reason claim denial codes and the lack of automated systems

RANKDENIAL CODE DENIAL DESCRIPTION

# OFCLAIMS/DENIED

%OF

CLAIMS

1 5HC01 The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely

108 29%

2 5HY01 The medical documentation submitted did not show that the 42 11%therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist

3 5HN18 Skilled nursing services were not medically necessary 38 10%

4 5HC08 The recertification estimate of how much longer skilled services are required is missing/incomplete/invalid

26 7%

5 56900 Requested documentation not received/received untimely 22 6%

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This should mean that it is a whole team approach. From the initial point of care to making a claim for billing, the careful start of care should limit the need for the billing department to have to spend additional time in figuring out what is missing and tracking down the necessary parties.

• 90% of claims are preventable, but still occur

• Most claims are denied for the following reasons:

1. Missing information – such as missing patient demographic data and technical errors

2. DUPLICATE claim submissions3. Services not covered by the payer4. Time limit for claim submission has already passed

Too often health care providers are getting charges entered and bills out the door and then wait to correct the claim denials. This is an inefficient process, it delays payment and reduces the probability of payment. Healthcare providers need to be more proactive. The whole health care team should instead focus on the key to more proactive processes to ensure patient and insurance data is accurately collected and reported before or at the Point Of Service.

Front end staff need to work with claim denial staff to understand what patient and insurance data are necessary to make a claim for payment. Remember, there is no recourse if you miss a deadline, the money is lost forever! The appeal process study demonstrates that this strategy is process study demonstrates that this strategy is not the opportunity for providers to recoup lost revenue but a cost to providers. The AMA study showed that practices spend roughly $15,000 on reworking claims. Another important note is that providers billing Medicare spent in the first quarter of 2016 more than $10,000 on managing Medicare recovery.

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CY 2017 National,

Standardized 60-Day Episode

P t

Wage Index Budget

Neutrality Factor

Case-Mix WeightsBudget

Neutrality F t

Nominal Case-Mix

Growth Adjustment

CY 2018 HH

Payment Update

CY 2018 National, Standardized 60-Day

Episode Payment

Table 1: For HHAs that DO Submit Quality Data –National, Standardized 60-Day Episode Amount for CY 2018

Payment Factor

$2,989.97 X 1.0004 X 1.0160 X 0.9903 X 1.01 $3,039.64

Table 2: For HHAs that DO NOT Submit Quality Data –National, Standardized 60-Day Episode Amount for CY 2018

CY 2017 National,

Standardized 60-Day Episode

Payment

Wage Index Budget

Neutrality Factor

Case-Mix WeightsBudget

Neutrality Factor

Nominal Case-Mix

Growth Adjustment

CY 2018 HH

Payment Update

CY 2018 National, Standardized 60-Day

Episode Payment

$2,989.97 X 1.0004 X 1.0160 X 0.9903 X 0.99 $2,979.45

HH Discipline Type

CY 2017Per-Visit Payment

Wage Index Budget

Neutrality Factor

CY 2018 HH

Payment Update

CY 2018 Per-VisitPayment

Table 3: For HHAs that DO Submit Quality Data – CY 2018 National Per-Visit Amounts for LUPAs and Outlier Calculations

Factor UpdateHome Health Aide $ 64.23 X 1.0010 X 1.01 $ 64.94

Medical Social Services $227.36 X 1.0010 X 1.01 $229.86

Occupational Therapy $156.11 X 1.0010 X 1.01 $157.83

Physical Therapy $155.05 X 1.0010 X 1.01 $156.76

Skilled Nursing $141.84 X 1.0010 X 1.01 $143.40

Speech – Language Pathology $168.52 X 1.0010 X 1.01 $170.38

HH Discipline

CY 2017Per Visit

Wage Index Budget

Neutrality

CY 2018 HH

Payment CY 2018 Per Visit

Table 4: For HHAs that DO NOT Submit Quality Data – CY2018 National Per-Visit Amounts for LUPAs and Outlier Calculations

Discipline Type

Per-Visit Payment

Neutrality Factor

Payment Update

Per-VisitPayment

Home Health Aide $ 64.23 X 1.0010 X 0.99 $ 63.65

Medical Social Services

$227.36 X 1.0010 X 0.99 $225.31

OccupationalTherapy

$156.11 X 1.0010 X 0.99 $154.70

Physical Therapy $155.05 X 1.0010 X 0.99 $153.65

Skilled Nursing $141.84 X 1.0010 X 0.99 $140.56

Speech – Language Pathology

$168.52 X 1.0010 X 0.99 $167.00

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CY 2017 NRS Conversion Factor

CY 2018 HH Payment Update

CY 2018 NRS Conversion Factor

$52.50 X 1.01 $53.03

Table 5a: CY 2018 NRS Conversion Factor for HHAs that DO Submit the Required Quality Data

Table 5b: CY 2018 Relative Weights and Payment Amounts for the 6-Severity NRS System for HHAs that DO Submit Quality Data

Severity Level Points (Scoring) RelativeWeight CY 2018 NRS Payment Amounts

1 0 0.2698 $14.31

2 1 to 14 0.9742 $51.66

3 15 to 27 2.6712 $141.65

4 28 to 48 3.9686 $210.45

5 49 to 98 6.1198 $324.53

6 99 + 10.5254 $558.16

Table 6a: CY 2018 NRS Conversion Factor for HHAs that DO NOT Submit the Required Quality Data

CY 2017 NRS Conversion Factor

CY 2018 HH Payment Update Percentage Minus 2 Percentage Points

CY 2018 NRS Conversion Factor

$52.50 X 0.99 $51.98

Table 6b: CY 2018 Relative Weights and Payment Amounts for the 6-Severity NRS System for HHAs that DO NOT Submit Quality Data

Severity Level Points (Scoring) RelativeWeight CY 2018 NRS Payment Amounts

1 0 0.2698 $14.02

2 1 to 14 0.9742 $50.64

3 15 to 27 2.6712 $138.85

4 28 to 48 3.9686 $206.29

5 49 to 98 6.1198 $318.11

6 99 + 10.5254 $547.11

HH DisciplineAverage Minutes

CY 2018 Per Visit

Cost Per Unit(1 Unit = 15 Minutes)

Table 7a – Cost-Per-Unit Rates for Calculating Outlier Paymentsfor HHAs that DO Submit Required Quality Data

HH Discipline Minutes Per-Visit

Per-Visit Payment

(1 Unit = 15 Minutes)

Home Health Aide 63.0 $64.94 $15.46

Medical Social Services 56.5 $229.86 $61.02

Occupational Therapy 47.1 $157.83 $50.26

Physical Therapy 46.6 $156.76 $50.46

Skilled Nursing 44.8 $143.40 $48.01

Speech-Language Pathology 48.1 $170.38 $53.13

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Methodology For CalculatingMethodology For CalculatingOutlier Payments (Continued)Outlier Payments (Continued)

Table 7b – Cost-Per-Unit Rates for Calculating Outlier Paymentsfor HHAs that DO NOT Submit Required Quality Data

HH DisciplineAverage Minutes

i i

CY 2018 Per-Visit

Cost Per Unit(1 Unit = 15 Minutes)

Per-Visit Payment

Home Health Aide 63.0 $63.65 $15.15

Medical Social Services 56.5 $225.31 $59.82

Occupational Therapy 47.1 $154.70 $49.27

Physical Therapy 46.6 $153.65 $49.46

Skilled Nursing 44.8 $140.56 $47.06

Speech-Language Pathology 48.1 $167.00 $52.08

2017 new payment system for physicians was implemented and providers of wound care took notice. Since then rather than receiving payment changes based on the country’s economic growth, physicians will no longer receive Medicare Physician Fee scheduled increases/decreases at the end of 2018. Their Medicare allowable rates will remain flat starting in 2019.

The new direction will either provide bonuses or deductions from their flat payment t b d f f t irates based on four performance categories:

1. QUALITY

2. ADVANCING CARE INFORMATION

3. CLINICAL PRACTICE IMPROVEMENT

4. TOTAL COST OF CARE (NOT JUST THE COST OF ITEM OR PROCEDURE)

The focus is now upon quality of care and total cost of care based on clinical guidelines and will make better use of electronic health records to communicate across the continuum of care.

Physicians will now develop wound care plans based on the 4 performance categories which focuses on value- based care rather than volume-based care.

Example: Focus will be placed on E/M and de-emphasize procedures, focus on early diagnostics and de-emphasize multiple surgical procedures, focus on debridement products, the patient can use themselves and de-

h i d b id d f d b h i i d h f emphasize debridement procedures performed by physicians and the focus goes on.

By now, wound care professionals realize that they must adjust their volume-based practice to align with value-based care for patients, physicians, providers and payment.

One thing is for sure, as health professionals, we know change is always present in practices and wound care professionals know how to manage wounds from the beginning to the end and are open to developing a new model of care for patients wherever they are and not just in the site of care.

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