Welcome to the IHS Clinical Rounds June 14 th , 2012 Host: Susan - - PowerPoint PPT Presentation
Organizing a Wound Healing Program: Replicating a Model That Works Welcome to the IHS Clinical Rounds June 14 th , 2012 Host: Susan Karol, MD; IHS Chief Medical Officer Presenter: John Farris, MD; CMO, IHS Oklahoma Area Objectives for
June 14th, 2012
healing within Indian health care.
healing program
program.
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ihs.gov) or Mollie Ayala (mollie.ayala@ihs.gov).
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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
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
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.
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
approach to healing wounds for American Indians
program on patient outcomes and satisfaction, the financial impact on the facility, and barriers they will face with implementation
25.2 77.7 119.3 20 40 60 80 100 120
the U.S. have diabetes
diabetes.
diagnosed diabetes, with rates varying by region from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona.
15.2%
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
1. Lee JS, Lu M, Lee VS, Russell D, Bahr C, Lee ET: Lower extremity
risk factors, and mortality in the Oklahoma Indian Diabetes Study.
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.
higher level of co-morbid conditions
and Peripheral Arterial Disease is insufficient
many providers as definitive care for even simple wounds
is not readily available
continuity of care
designed to merge the needs of patients with wounds that require extra time and special interventions
practice of utilizing CHS funds for either convenience referrals or emergent/urgent care
200 400 600 800 1000 Cancer PAD and DFU/Wounds National Defense HHS Overall
without consistent results
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)
infection.1
hospitalization 55.7 times and the risk for amputation 155 times.1
partial foot amputations at the Phoenix Indian Medical Center.”2
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
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
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
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
the persons experience
“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
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”.
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
comfort level and treated based on personal preference
documentation, policies or procedures
clinic”
patients with wounds
medications, ability to document and bill for wound related services, policies and procedures for patients with wounds
Plan Do Check Act Re- evaluate
Diagnostic Radiology Nutrition Vascular Surgery Behavior Health PHN/CHR Plastic Surgery Dermatology Pedorthist/ Diabetic Shoes Infectious Disease Naturopathic Traditional Medicine Endocrine Nephrology Wound Clinic: Hub of Care Coordination
with wounds at all sites offering wound clinic
improvement
– 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
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
(confirmed on x-ray there was not joint involvement of infection prior to starting OP
Cost of care <$3,000 vs. cost of Plastic Surgery ?
Sinus tracks from infection 7 – 9 cm in length
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
treatments, or supplies dictates
Results
record Patient care adjusted or care coordinated
Rethink – ‘evaluate and treat’ referrals
to care
Organized Program Meets or exceeds Standards of Practice Independent Documents
Committed and accountable Standardized Multi- disciplinary
Most perceptions of wound care is that “we are already doing a good job”
– 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
program with an overall decrease for the Area of 36%
include ‘field tested’ treatments
Consider the culture Consider the impact
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
– Adopt a best practice model – Reduce amputations – Enrich the use of CHS funds
– Assure Improved Patient Care
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:
Oklahoma City Area 405-951-3776