welcome to the ihs clinical rounds · directors/coordinators, planning committee members, faculty,...
TRANSCRIPT
Host: Susan Karol, MD;
IHS Chief Medical Officer
Welcome to the IHS Clinical Rounds June 14th, 2012
Presenter: John Farris, MD;
CMO, IHS Oklahoma Area
“Organizing a Wound Healing Program:
Replicating a Model That Works”
Objectives for Today’s Rounds
• Define the key factors for developing an organized approach to wound
healing within Indian health care.
• Differentiate between healing wounds and building an organized wound
healing program
• Implement processes and strategies for a comprehensive wound healing program.
Accreditation
• The Indian Health Service (IHS) Clinical Support Center isaccredited by the Accreditation Council for Continuing MedicalEducation to sponsor continuing medical education for physicians.The IHS Clinical Support Center designates this live educationalactivity for a maximum of 1 AMA PRA Category 1Credit(s)™. Physicians should claim only the credit commensuratewith the extent of their participation in the activity.
• The Indian Health Service Clinical Support Center is accredited as aprovider of continuing nursing education by the American NursesCredentialing Center’s Commission on Accreditation.
• This activity is designated 1.0 contact hours for nurses.
Accreditation applies solely to this educational activity and does
not imply approval or endorsement of any commercial product,
services or processes by the CSC, IHS, the federal
government, or the accrediting bodies.
Disclaimer
Guidelines for Receiving
Continuing Education Credit
• To receive a certificate of continuing education or certificate of
attendance, you must attend the educational event in its entirety and
successfully complete an on-line evaluation of the seminar within 15
days of the activity. At the end of the evaluation, click on the
appropriate line to obtain your certificate, fill in your name and print
the certificate.
• If you need assistance, please contact Dr. Chris Fore (chris.fore@
ihs.gov) or Mollie Ayala ([email protected]).
Faculty Disclosure Statement
• As a provider accredited by ACCME, ANCC, and ACPE, the IHSClinical Support Center must ensure balance, independence,objectivity, and scientific rigor in its educational activities. Coursedirectors/coordinators, planning committee members, faculty, and allothers who are in a position to control the content of this educationalactivity are required to disclose all relevant financial relationshipswith any commercial interest related to the subject matter of theeducational activity. Safeguards against commercial bias havebeen put in place. Faculty will also disclose any off-label and/orinvestigational use of pharmaceuticals or instruments discussed intheir presentation. Disclosure of this information will be included incourse materials so those participating in the activity may formulatetheir own judgments regarding the presentations. The coursedirectors/coordinators, planning committee members, and faculty forthis activity have completed the disclosure process and haveindicated that they do not have any significant financial relationshipsor affiliations with any manufacturers or commercial products todisclose.
Topics for Future Rounds
July 12, 2012: “The Baby Friendly Hospital Initiative”
Suzan Murphy RD MPH; Phoenix Indian Medical Center
August 9, 2012: “Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes”
Ann Bullock, MD; Cherokee Hospital
Sept 13, 2012: “Improving Timing Stroke Care: Advances in Tele-Stroke
Consultation” Dr. Bart Demaerschalk; Mayo Clinic
Meet the Presenter
Dr. John Farris is the Chief Medical Officer for the Oklahoma City Area Indian
Health Service and a member of the Cherokee Nation of Oklahoma. He attended
undergraduate schools at the University of Oklahoma in Norman, OK and Baker
University in Baldwin City, Kansas, attaining a B.S. in Biology in 1981. He attended
medical school at the University of North Dakota, School of Medicine in the INMED
Program and completed his medical education at Michigan State University College
of Human Medicine, receiving his medical degree in 1985. He completed an Internal
Medicine Residency at the University of South Dakota, School of Medicine, in Sioux
Falls, South Dakota, and also served as the Chief Resident in Internal Medicine for 1
year.
After residency, Dr. Farris worked as a staff physician in the Internal Medicine
Department and then was appointed medical director of the Respiratory Therapy
Department at the VA Medical Center in Ft. Meade, South Dakota. In February,
1996, he joined the staff at W.W. Hastings Indian Hospital in Tahlequah, Oklahoma
as the Director of the Emergency Department and was selected as Clinical Director
in November 1996. In August of 2004, he assumed the Chief Medical Officer duties
for the Oklahoma City Area.
“Organizing a Wound
Healing Program:
Replicating a Model That
Works”
John Farris, MD, Chief Medical Officer
Indian Health Service – Oklahoma City Area
Indian Health Service Clinical Rounds
June 14, 2012
IHS Priorities
Dr. Yvette Roubideaux - Indian Health Service Director
1. To renew and strengthen our partnership with tribes
2. In the context of national health reform, to bring reform
to IHS
3. To improve the quality of and access to care
4. To make all our work accountable, transparent, fair and
inclusive
Objectives:
1. Describe the factors in developing an organized
approach to healing wounds for American Indians
2. Highlight the difference between having an organized
wound healing program and treating wounds
3. Understand the implementation of a comprehensive
program on patient outcomes and satisfaction, the
financial impact on the facility, and barriers they will
face with implementation
DIABETES In America
• 23.6 million people in
25.2
77.7
119.3
0
20
40
60
80
100
120
the U.S. have
diabetes
• ¼ don’t know it
• 15% will develop
Diabetic Foot Ulcers
(DFU)
• Death rates are
increasing
2011 National Diabetes Fact Sheet
14.2% of American Indians and Alaska Natives aged 20 yearsor older who received care from IHS have diagnoseddiabetes.
16.1% of the total adult population served by IHS hasdiagnosed diabetes, with rates varying by region from 5.5%among Alaska Native adults to 33.5% among American Indianadults in southern Arizona.
Among Native Americans in Oklahoma the rate of diabetes is15.2%
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Wounds: a serious health risk predictor for
Native Americans…
1. Lee JS, Lu M, Lee VS,
Russell D, Bahr C, Lee
ET: Lower extremity
amputation. Incidence,
risk factors, and
mortality in the
Oklahoma Indian
Diabetes Study.
Diabetes. 1993:42:876-
82.b
Do diabetes-related wounds
and amputations cost more lives
than some cancers? YES! Nearly half of all
unhealed neuropathic
ulcers have other co-
morbid states that will
result in patient death
within 5 years if not
resolved
ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 4 No 4strong 2007;4(4):286-287.
Disparity Exists for Indian Health
Service Patients
• Wound patients have ahigher level of co-morbidconditions
• Education on risk factorsand Peripheral ArterialDisease is insufficient
• Amputations are viewed bymany providers as definitivecare for even simplewounds
• Consultation with specialistsis not readily available
• There is no mechanism forcontinuity of care
• Clinic structure is notdesigned to merge theneeds of patients withwounds that require extratime and specialinterventions
• There is a consistentpractice of utilizing CHSfunds for eitherconvenience referrals oremergent/urgent care
National Economic Costs Comparisons…
0
200
400
600
800
1000
Cancer PAD andDFU/Wounds
NationalDefense
HHS Overall
$227
$515
$671
$892
$ B
illio
n
Why did we develop a Direct Wound Care
Program
Increasing expenditures to care for patients with wounds
without consistent results
Increasing amputations
Oklahoma City Area cost for outsourced wounds averaged more
than $17,000 - $22,000 for even simple wounds;
CHEF cases that began as wounds often exceeding $1 million dollars
with devastating patient outcomes (2004 dollars)
Complications of Diabetic Foot Ulcers
DFUs that persist more than 4 weeks have a 5-fold greater risk of
infection.1
Development of an infection in a foot ulcer increases the risk for
hospitalization 55.7 times and the risk for amputation 155 times.1
“Infected neuropathic ulcerations are the leading cause of diabetes-related
partial foot amputations at the Phoenix Indian Medical Center.”2
Foot ulceration is a significant risk factor for lower-extremity amputation in
Native American Indians.3
19
1. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.2. Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr
Med Assoc. 1989;79:447-50.3. Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care.
1996;19:704-9.
Diabetes Neuropathy Infection Amputation Foot Ulcer
Costs of Letting Wounds Progress
6. Kruse I, Edelman S. Evaluation and Treatment of Diabetic Foot Ulcers. Clinical Diabetes. 2006;24 (2):91-93.
7. Stockl K, et al, Costs of Lower-Extremity Ulcers Among Patient with Diabetes. Diabetes Care 27:2129-2134, 2004.
8. Reiber, GE, Boyko EJ, Smith DG. Lower Extremity Foot Ulcers and Amputations in Diabetes. In Diabetes in America, 2nd edition. Bethesda, MD; National Diabetes
Data Group, National Institutes of Health, NIDDK NIH Publication No. 95-1468, 1995.
<$200 to $3,600 $5,000 - $12,000 $19,000 to >$103,000
Wounds Have a “Golden Hour”
From the onset of the wound…patients need
definitive wound care sooner than later
30 days to prevent further breakdown,
infection, progression to amputation
Case Examples:
With Organized Direct Care Wound Program 42 y/o male with scrotal abscess
I&D including brief IHS hospital post-op stay w/referral to
wound care
Remained outpatient w/return to work in 5 weeks
Cost of care: @ $2,000
Without Organized Wound Care 44 y/o male with scrotal abscess I&D including brief hospital
post-op stay w/o referral to wound care Became septic w/exacerbation of other co-morbid conditions
hospital readmission and transfer to private sector ICU
Cost of care: >$1 million
Aggressive treatment leads to fast healing…
20 y o male with full thickness burns to left foot from heat exposure in bon fire
incident; ED visit Saturday night. Patient presented two days after insult with
loose rupture blisters and open wounds to lateral aspect of foot 6 inches long;
blisters to base of great toe; and plantar surface injury. The loose tissue was
debrided, dressed per wound protocols, given antibiotics/pain RX, supplies for
dressings and with RTC in one week. Four weeks later patient was healed of all
wounds – cost of care: <$150.00
Quality of the
person’s experience
Dollars spent
For the full cycle of care
Quality includes clinical outcomes and
the persons experience
>99% Patient Satisfaction Rates
Patients Do Notice:
“I have almost given up hope for my sister’s ulcerated sore on her right foot, since she
has been in a wheel chair for 7 years. Her daily activities have been very limited because
of her foot. She’s been in and out of the hospital for it. Twice she’s been told amputation
maybe a last resort, but twice we have pleaded with the doctors for alternative.
I am truly grateful for the good doctors, and nurses, and staff who does all this hard work.
I know because since my sister started in this program in February and up to now, this is
the miracles I have been witnessing that it works. The deep wide hole that was once
there is now a scar, a reminder of how lucky my sister is to still have her foot”!
“I cannot tell you what the program has done for me. Both my leg and my head. I was
trying to live with my leg the way it was and never dreamed there was any more than
could be done. I am so ecstatic with the improvement that have already given me that I
have gone out, bought a bike and am riding around our wonderful National Parks trying to
lose this extra weight that I have. To say, “thank you” doe not even begin to tell you how
positive and encouraged I am and also my family.
Yes the IVIVI has take the swelling way down. My ankles are almost the same size. I also
think that the pocket of infection is draining less. I am using my leg more and the swelling
is almost non-existent. I will be good about using it for the rest of my season here,
although my driver accuses my of shorting out my wireless mike.
I am so happy with what we have done so far, I can’t wait to try this other thing.”
“Good Morning, I just wanted you to know that the Indian Health Service Wound Care
team has saved my mother’s feet again and immediately addressed the wound issues
that have plagued my mom since August. I cannot tell you how much I appreciate this
program and the Clinic staff. Everyone was courteous, knew the goals, knew how to
help each other and my mom was impressed with their care to her just not trying to
herd her in so that they can get her out. I am truly thankful to everyone. Just a huge big
thanks”.
Case Examples:
patient satisfaction counts
Received patient after 7 months of open
wound with dry dressing; current
treatment – recommended by outside
podiatrist – dry dressings with monthly
follow-up visits; amputation anticipated
with further deterioration of the wound.
Treatment has been complex but the
patient is highly satisfied with the care
and will not require surgical intervention
to heal the wound.
Cost to treat the osteomyelitis: <$1000
for the Tornier calcium sulfate mixture
and topical antibiotics/antifungal.
Exposed bone
Nephrologist
Typical Care Structure: Wounds
Approach to Healing Wounds:
Incidental vs. Organized
• Patients seen in general clinic
• Wounds referred based on provider
comfort level and treated based on
personal preference
• No wound care specific formularies,
documentation, policies or
procedures
• Patients seen in blocked “wound
clinic”
• Staff trained in wound care treating
patients with wounds
• Specific formularies for supplies and
medications, ability to document and
bill for wound related services,
policies and procedures for patients
with wounds
Use an organized approach to
change
Plan
Do
Check
Act
Re-evaluate
Diagnostic Radiology
Nutrition
Vascular Surgery
Behavior Health PHN/CHR
Plastic Surgery Dermatology Pedorthist/
Diabetic Shoes
InfectiousDisease
Naturopathic Traditional Medicine
Endocrine Nephrology
Wound Clinic: Hub of Care Coordination
Wound Healing Model
Define the Scope of Care
• Meet or exceed the Standard of Practice
• Use established proven clinical pathways, treating all wound types
• Re-organize and standardize supplies and medication formularies specifically for patients
with wounds at all sites offering wound clinic
• Offer advanced and adjunctive therapies
• Control CHS referrals: no “evaluate and treat” be specific
• Gather data to benchmark against other wound programs and identify areas for
improvement
• Improve and investigate all wound care reimbursement avenues
• Streamline access to wound clinic
Clinical Pathways save time,
money, and improve practice
– Cost increases with time – designed to heal for the least cost
with aggressive early intervention
– Addresses root cause of the problem to assist with clinical
decisions and pathway application
– Pathways that clinically produce a >90% heal rate
– Pathways include: x-rays, lab, sharp conservative debridement,
management of infection and edema, dressings and off-loading,
advanced treatment modalities
Re-organize and standardize
supplies and medications
for patients with wounds
• Reduces waste and duplication
• Easier to learn and apply
• Helps to contain and predict costs
• Communicates a message of clinical competency and
organization
• Encourages system wide availability of formulary items
• Promotes consistent patient care
Adjunctive/Advanced Treatment Modalities
PRP and Living Cell Therapy
Negative pressure wound therapy
Pulsed Electro Magnetic Field therapy (PEMF)
Ultrasound Debridement
Topical Oxygen therapy
Case Examples:
Advanced Therapy in clinic – no surgery
Initial Referral to Plastic Surgery – referred to
wound clinic to confirm need for referral –
Female in mid twenties with traumatic
Seroma from Auto vs. Pedestrian incident,
evaluated and treated as outpatient,
effectively healed using advanced therapy,
aggressive topical bio-burden management
while patient worked; no functional disability
or restrictions; no residual joint pain.
(confirmed on x-ray there was not joint
involvement of infection prior to starting OP
treatment. Patient has remained healed.
Cost of care <$3,000 vs. cost of Plastic
Surgery ? 3
Sinus tracks from
infection 7 – 9 cm in
length
CHS Referral Adjustment Healing Need
Identified
Not available in wound clinic
Referral
To
CHS
Be specific about the need – refrain from Evaluate and Treat
Referrals as a routine
Resume care for the wound as soon as possible; no outside
orders for wound care treatments, or supplies
dictates
Results obtained for the
record
Patient care adjusted or
care coordinated
Rethink –
‘evaluate
and treat’
referrals
Obstacles to Achieving Greater
Value in Wound Healing
– Policy and funding barriers
– Not understanding and mitigating patient limitations
– Lack of “buy in” by clinicians
– Clinician non-compliance with treatmentrecommendations
– Skipping steps in the pathways
– Identifying appropriate clinical approaches
– Lack of wound specific supplies/advanced therapy
– Wait and see medicine
– Premature discharges and inappropriate transfers
Bolster Competencies and Build
Consistency Bolster Competencies
through:
Clinical Experience/Mentoring
• Billing/Coding Assessment
• Documentation Awareness
• Training
Build Consistency
through:
Increasing knowledge
Understanding biases
Case review/reflection
Pathway Compliance
Change is not always easy…
• Recognize there is a opportunity; build in reform
• Make the most of the work of others
• Re-design processes to improve the quality of and access
to care
• Meet the needs of our patients
• Identify and diminish system weaknesses
• Develop an internal culture of change
• Support the transition for the team
HOW SHOULD AN ORGANIZED
PROGRAM LOOK?
Organized Program
Meets or exceeds
Standards of Practice
Independent
Documents outcomes
Committed
and
accountable
Standardized
Multi-disciplinary
Wound Care Should:
If you don’t test; you guessed…
Most perceptions of wound care is that “we are already doing a
good job”
• Tracking simple data elements can give you a lot of information
• First year experience
– 3171 total patient visits – 265 visits per month
– 113 active patients
– 446 new patients
– 333 healed patients
– Cost per healed patient $3603; with advanced therapy @$4250
– CHS savings of $6 million
Wound Program Results
• Amputations decreased to less than 2% for patients in theprogram with an overall decrease for the Area of 36%
• Less than 3% recidivism rate
• Almost zero ‘no show’ rate
Be open to suggestions
• Not ‘cook book’ medicine
• Designed to support standardization and best practice; may
include ‘field tested’ treatments
• Designed to ‘assist’ clinical decisions
• Promotes revision of care guidelines and best practice
• Requires a commitment to ongoing education
• Identifies key elements of collective importance
• Used to benchmark care
Driven by the need of the patients
• Consider the patient
Consider the culture
Consider the impact
• Looks at current process
A program should:
• Foster community participation, and
• Make it easy for patients to participate
Essentials for a Wound Healing Program
1. In the simplest form, wound clinic essentials
include:
a) supporting policies/procedures and training
b) wound care provider (physician or mid-level)
c) support staff: nurse to assist provider
d) supplies and medications to support multi-modal treatment options
(Pharmacy and Supply Formularies)
e) clinic space to conduct clinic including: podiatric/wound care chair, and
locking storage, instruments/equipment
Time is More than Money –
Build on a proven platform
• Simple adjustments in practice, flow, and care can
produce great benefit:
– Adopt a best practice model
– Reduce amputations
– Enrich the use of CHS funds
– Assure Improved Patient Care
Just because you’ve done it that
way…
In the end…
It’s all about the patients.
Next Steps…
1. Would an organized approach save your patients amputations?
2. Would an organized approach add value and save limited
healthcare dollars for your facility?
3. What barriers do you anticipate if you choose to modify your
current program?
Contact:
Dr. John Farris, Chief Medical Officer
Oklahoma City Area
405-951-3776