Paula Erwin Toth, RN, MSN, FAAN
By Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN
Editor's Note: This letter originally appeared in the print edition of WoundSource 2014.
There's a lot to be said about change, and much of what you say depends on which end of change you are on. Those of us who are early adopters of new products, technology or ideas get an adrenaline rush with just the hint of change. We love that feeling of freshness— finding the bumps in the road, meeting the challenges head on and solving the issues at hand. Then we help those who come after us—mentoring them over the hurdles we've overcome as the pioneers in a new territory. We are not early adopters, we are early adapters.
There is a yin to every yang. Others of us are the traditionalists. We like the tried and true. We roll our eyes and cringe at the thought of altering the routine. Many of us have seen this thing called change as a flash in the pan. The more things change, the more they stay the same. We are abstainers. The process of change is much like testing to see whether pasta has been cooked to perfection—throwing it against the wall and if it sticks, it's ready! We accept change gradually when we see what stays glued to the walls. We still do wet-to-dry dressings.
Most of us fall between the continuum of the early adapter and the abstainer. In reality, death, taxes and change are the only certainty. This year, perhaps more than any other, blows a whirlwind of change. No, make that an F-5 tornado. Here are the forces that make up this blustery weather altering the landscape.
Impact of the Affordable Care Act
My colleagues on the Woundsource.com blogs have been quite articulate in expressing the impact of the Affordable care Act. If you have a spare moment, take a look. Politics aside, not one of us in health care will be left "unchanged." Providers are consolidating into large group practices, accountable care organizations are forming and economy of scale is the prime objective. The focus is on production: how many patients did you see today? Did you exceed the number of "dives" this month?
The increasing number of patients entering the system will increase our workloads. Obesity and diabetes rates climb annually, bringing more people into the system because of increased access. We are adapting, albeit slowly. As providers, we value prevention, but we are slow to put prevention programs in place. It is scary to think that the five-year mortality rate for a patient with a diabetic foot ulcer is now higher than that for a patient with either breast or colon cancer.1 The Save a Leg, Save a Life Foundation (SALSAL) is one organization of care providers who have become early adapters and are trying to change outcomes. This year WoundSource published a guide to organizational contact information and listings of educational resources for its readers, available as a free download at Woundsource.com in the White Paper center.
Changes in How Providers and Organizations Document Care
Electronic medical records must be in use by 2015 or reimbursement penalties will be enacted. The definition of 2015 by government agencies really means October 1, 2014. There are exemptions and delays that one can apply for, but we will all be wired and, in theory, duplicating fewer services and improving outcomes. To get proof of concept, the data needs to be markedly more refined. As a means of doing this, the ICD-9 system will be upgraded to ICD-10—going from 3,824 procedure codes associated with 14,025 diagnosis codes to 71,924 procedure codes and 69,823 diagnoses2 that describe our daily activities. This gust of change was not intended to debut in 2014. It's late by several years. Currently, there are several organizations making a strong push to delay its introduction, and by the time you are reading this, there may be a stay of execution.
With this change, as with most of its widespread, system-affecting brethren, there will be a learning curve. A steep one. It may take several years to be able to make good clinical decisions and tie reliable reimbursements and outcomes to reliable data that will be extracted from the information base. We know this from experience. In 2014, cell-based therapy reimbursements were changed. The change occurred based on the data that bedside clinicians entered into a long-established ICD-9 and CPT coding system we all thought we understood, but didn't. The end result? our well-intentioned but ill-informed input of data has affected our daily clinical decision making.
In 2014, another documentation change will affect providers of care and health care systems. Individual providers will need to report three process measures on patient encounters so as not to incur a 2% reduction in reimbursement for 2016. Previously, there was a requirement of reporting only one process measurement, with the failure to do so impacting reimbursement by 1% in 2015. What specific process measures can wound care providers report? not performing wet-to-dry dressings is one such example. But there are others, such as not performing wound cultures. This latter example has many specifics and caveats, and the rationale is supported by good evidence.3 of the 358 measures from which providers can choose, only a few are specific to wound care.
Acute care facilities and system-wide organizations will have more outcomes to report in the windblown year of change—primarily those that promote patient safety and satisfaction. Evaluation of products has gone away from individuals and toward groups. The herd mentality gives balance as evidence is sifted though sometimes at the price of efficiency. Having WoundSource handy for all team members can allow quick comparisons between products.
Reinvention of the Team
Perhaps the hardest shift will be to redefine our roles on the health care team. The evolution of medical homes, the multidisciplinary team, daily huddles and as yet undiscovered practice innovations will have a distinct fluidity. These shifts developing over time give pause to even the most change-hardy individual. The wound team is, by nature, not static. Sometimes you need the vascular surgeon and sometimes you need the WOCN. However, the whole team will effortlessly flow in and out of bigger teams based on the clinical setting of the patient and etiology of the wound. As the health care system shifts gradually toward payment for episodes of care, rather than fee-for-service,4 those of us in wound care will need to be thinking about "what matters" and how to articulate it to those who may wish to engage our services.
Want to know the scariest part of all? Allowing the patient into the inner circle! We need our wound care patients as much as they need us. The patient-provider disconnect has been well articulated,5 and there is a great need to create a true alliance so that the specialty of wound care can develop and substantiate patient-centered outcomes that are evidence-based. David Sackett,6 the founder and definer of evidence-based practice, expressed this long ago. Evidence-based practice relies on three things: the best available clinical evidence, clinician expertise and the patient's values.
How Do We Weather Change?
We do know that getting out of a rut avoids the grave, as the only difference between the two is depth. To survive change, adapters aim to thrive. Try varying your daily routine in a small way, and you will see things differently. Learn from nature. For example, experts tell you if you are thrown from your boat in a raging river, don't try to swim upstream. You will drown. Instead, put your feet up and keep them pointed downriver. Your flexibility will allow you to see what's coming, and you will not be expending energy that will be useful later. Go with the flow while keeping a watchful eye ahead. When change is pushing you in one direction, do not stiffen up.
One of the best ways to thrive in a changing environment sounds easy but requires focus. Prepare. Actively seek information, get involved in your professional organization and network. The more you know about the opponent named change, the more adaptive strategies emerge. Many times unseen opportunities will also arise, allowing one to flourish. Our patients depend on this.
As we enter into the hurricane forces of change in 2014, it is nice to know that WoundSource remains dedicated to giving clinicians the best available information about products in both a hard-copy format and on the web. I am honored to have been asked to be this year's WoundSource clinical editor and look forward to working with each and every one of our readers to bring the best to our patients.
1. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286.
2. Centers for Disease Control and Prevention. International classification of diseases (Icd-10/PcS) Transition. Available at: www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm. Accessed March 15, 2014.
3. Centers for Medicare & Medicaid Services. 2014 Physician quality reporting system (PQrS) measure specifications manual for claims and registry reporting of individual measures. Page 467. Available at: www.cms.gov/Medicate/Quality-Initiatives-Patient-Assessment-Instruments/.... Accessed March 15, 2014.
4. Stefanacci RG, Spivack B. Looking ahead to issues affecting geriatric care in 2014. Ann Long-Term Care. 2013; 21(12):46-50.
5. American College of Wound Healing and Tissue Repair and the Angiogenesis Foundation. Patient-centered outcomes in wound care. V1.0 december 2013. Available at: https://acwound.org/news/WoundcareWhitePaper.pdf. Accessed March 1, 2014.
6. Sackett DL, et al. Evidence based medicine: What it is and what it isn't. BMJ. 1996; 312(7023):71-72.
About the Author
Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN, is the co-owner of Connecticut Clinical Nursing Associates, a practice focusing on direct patient care, consultation, education and research in the fields of wound, ostomy and continence care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.