Septebmer 2012 by HMP Communications, LLC

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TODAY’S

Contemporary Approaches to Wound Clinic Management

THE CHANGING FACE OF WOUND CARE:

RURAL HEALTH FOCUS ON: MAINTAINING A CARE CONTINUUM; MOBILE HEALTH; TELEMEDICINE ALSO IN THIS ISSUE: In Memoriam: Tribute to Robert A. Warriner III, MD Business Briefs

SAWCSPRING September 2012 www.todayswoundclinic.com

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Today’s

Volume 6, Number 7, September 2012 • www.todayswoundclinic.com

Table of Contents • Feature Articles 10

Wound Care On The Go

You’ve heard of “mobile” wound care, but what about “portable” wound care? Meet a physician who’s redefining the adage of making house calls through his own corporation, which is helping residents of East Aurora, NY, learn that optimal wound care is just a phone call away.

John A. Sterba, MD, PhD, FACEP

Establishing A Care Continuum In Rural America

When it comes to providing healthcare in a rural setting, nothing is a given.These regions are seeing fewer clinicians and more patients, especially those who continue to live with chronic wounds. But one dedicated provider is taking a stand in North Central Louisiana, not just for the improved outcomes of the area residents at large, but for his own family.

Frank Aviles Jr., PT, CWS, WCC, FACCWS, CLT

TODAY’S WOUND CLINIC® (ISSN 1938-6311), is published by HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. TODAY’S WOUND CLINIC® website, www.todayswoundclinic.com, is registered with all major Internet search engines. Full content is available online to TODAY’S WOUND CLINIC print subscribers. Subscriptions: TODAY’S WOUND CLINIC annual rates for US subscriptions: $99.00 annual; single copies, $39.00. ®

Single or replacement copies of TODAY’S WOUND CLINIC® are subject to availability. To subscribe to TODAY’S WOUND CLINIC , call (800) 237-7285, ext. 221, write to TODAY’S WOUND CLINIC®, Circulation Department, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, or visit us online at www.todayswoundclinic.com. ®

Reprints: Bulk professional-quality reprints (minimum quantity 100) of articles may be purchased. Contact the Managing Editor at (610) 560-0500 for information.

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Telemedicine: The Key to Opening the Door to Wound Closure in Rural Communities? At Archbold Medical Center,Thomasville, GA, use of telemedicine has allowed wound care providers to augment their overall presence in five surrounding counties. Learn how the “path” to advanced wound management has been repaved for their patients.

Harriett B. Loehne, PT, DPT, CWS, FACCWS

Advertising queries should be addressed to Jeremy Bowden, Publisher, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-4154 Fax: (610) 560-0501. Email: jbowden@hmpcommunications.com Display and classified advertisinG: HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, Phone: (800) 237-7285 or (610) 560-0500 x259 Corporate Offices HMP Communications, LLC 83 General Warren Boulevard Suite 100 Malvern, PA 19355 Phone: (610) 560-0500 or (800) 237-7285 Fax: (610) 560-0502

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EDITORIAL STAFF

TODAY’S

Volume 6, Number 7, September 2012 • www.todayswoundclinic.com

CLINICAL EDITORS AND FOUNDING BOARD Caroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS FOUNDING EDITORIAL BOARD Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS MANAGING EDITOR Joe Darrah jdarrah@hmpcommunications.com

Table of Contents

WEB EDITOR Samantha Alleman salleman@hmpcommunications.com

BUSINESS STAFF EXECUTIVE VICE PRESIDENT Peter Norris pnorris@hmpcommunications.com

In Memoriam

4 Remembering Robert A. Warriner III, MD: A Tribute to a True Leader Caroline Fife, MD, FAAFP, CWS

Departments 8

Business Briefs Call to Action: Start Preparing for ICD-10-CM

VP/GROUP PUBLISHER Jeremy Bowden jbowden@hmpcommunications.com PUBLISHER Kristen J. Membrino kmembrino@hmpcommunications.com NATIONAL ACCOUNT MANAGER Kevin Melesky kmelesky@hmpcommunications.com

HMP COMMUNICATIONS, LLC

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

PRESIDENT BIll Norton

TWC News Update

CONTROLLER Meredith Cymbor-Jones

Net Health acquires Wound Care Strategies; California hospital launches area’s first HBOT

VICE PRESIDENT, SPECIAL PROJECTS Jeff Hall

Advertiser’s Index

MARKETING MANAGER Stephanie Manzo CREATIVE DIRECTOR Vic Geanopulos vgeanopulos@hmpcommunications.com ART DIRECTOR Bernadette Zeminski bzeminski@hmpcommunications.com SENIOR PRODUCTION MANAGER Andrea Steiger asteiger@hmpcommunications.com

TWC Online

PRODUCTION/ CIRCULATION DIRECTOR Kathy Murphy kmurphy@hmpcommunications.com

www.todayswoundclinic.com Exclusive: From The Editor In honor of the late Robert A. Warriner III, MD, we’ve moved this month’s editorial online. Read co-editor Dot Weir’s salute to rural health on our homepage. Exclusive: Clinician’s Report: Hyperbaric Oxygen Therapy Find us on Facebook @ www.facebook.com/todayswoundclinic

AUDIENCE DEVELOPMENT MANAGER Bill Malriat MEETING PLANNER Tracy Blithe, CMP MEETING PLANNER Mary Beth Kurimay

HMP COMMUNICATIONS HOLDINGS, LLC CHIEF EXECUTIVE OFFICER Jeff Hennessy CHIEF FINANCIAL OFFICER Dan Rice SENIOR VICE PRESIDENT Anthony Mancini

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 Editorial Correspondence should be addressed to Managing Editor, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-0500 /Fax: (610) 560-0502. Editorial policy: TODAY’S WOUND CLINIC® seeks to provide practical, timely insight into clinical and operational issues inherent to the success of an outpatient wound center. Program Directors, Medical Directors, and Clinical Managers (including Nurse Practitioners and other professional wound care providers across multiple disciplines) will benefit from the interactive nature of feature articles and regular departments that address medical and practice management options and perspectives affecting fiscal and, most importantly, patient outcomes of wound clinics. Articles from knowledgeable, experienced practitioners are invited and will be subject to Editorial Board review. , LLC

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DIRECTOR OF E-MEDIA AND TECHNOLOGY Tim Shaw SR. MANAGER, IT Ken Roberts

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Precious life – Progressive care 1547741 A 0112 © 2012 Federal law restricts this device to sale or rental by or on the order of a physician. Avance Dressing Kits distributed by Medela, Inc. Medela and Invia are registered trademarks of Medela Holding AG. Liberty is a trademark of Medela, Inc. Avance is a registered trademark of Molnlycke. Medela, Inc. 1101 Corporate Drive, McHenry, IL 60050, USA Phone: 1 877 735 1626 Fax: 1 815 307 8942 suction@medela.com www.medelasuction.com

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inmemoriam Remembering Robert A. Warriner III, MD: A Tribute to a True Leader Caroline Fife, MD, FAAFP, CWS

obert A.Warriner III, MD, died Aug. 2, at the age of 62 after being diagnosed with multiple myeloma six years ago. During the final days of his illness, I visited Bob in the intensive care unit at MD Anderson Cancer Center in Houston, TX. Although he was very ill when I saw him, when I later received an email regarding a complicated question about hyperbarics, my first thought was,“I must remember to ask Bob what he thinks.” You see, asking Bob Warriner for his opinion had long been an ingrained habit of mine. For more than 20 years, there had not been a question, a crisis, an accomplishment, or an idea that I had not talked over with him. Around the world, many hyperbaric physicians share the same sense of professional “loneliness” since his death. A New Orleans native, Bob graduated from Tulane University andVanderbilt University School of Medicine. He trained in anesthesiology at Alton Ochsner Medical Foundation in New Orleans and conducted a critical care fellowship at Beth Israel Deaconess Medical Center and Harvard Medical School. From 1980-83 he served as the director of the surgical intensive care unit atWilford Hall on Lackland Air Force Base while serving in the Air Force. Additionally, at Luke Air Force Base in Arizona, he served as chief of anesthesia services, proudly attaining the rank of Major in the US Air Force Medical Corps.

A TRUE INSPIRATION When I arrived in Houston in 1990, fresh out of my hyperbaric medicine fellowship at Duke, Bob was one of the first professional colleagues I met. Over the years he became a friend,a collaborator,and a neighbor in The Woodlands,TX. Bob had moved to Texas after leaving the military, and in 1989 he founded the Southeast Texas Center for Wound Care and Hyperbaric Medicine in Conroe, serving as its director until 2003. During the 28 years that he lived in Montgomery County, Bob served as the county district EMS medical director and was named medical director for the EMT training program of North Harris/Montgomery College District and the Rural/Metro Ambulance Corps. In 1998, only days after I became president of the Undersea and Hyperbaric Medical Society, Medicare effectively withdrew hyperbaric oxygen therapy coverage for nonhealing wounds.Over

Around the world, many hyperbaric physicians share the same sense of professional ‘loneliness’ since (Dr. Warriner’s) death. the next two years, Bob and I made seven trips to the headquarters of the Centers for Medicare & Medicaid Services (CMS) to try to convince officials to abandon this decision, with each encounter

September 2012 Today’s Wound Clinic®

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*Stage III & IV pressure ulcers 1. Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Management. 2005 Sep;51(9):47-60. Acute care re-hospitalization (5% vs. 14%, p<.01) and emergent care needed (0% vs. 8%, p<.01) for wound problems for pressure ulcer patients was reduced when comparing the V.A.C.® Therapy group to the control group.1 2. Baharestani MM, Houliston-Otto DB, Barnes S. Early versus late initiation of negative pressure wound therapy: examining the impact on home care length of stay. ® Ostomy Wound Management. 2008;54(11):48-53. Early initiation of V.A.C. Therapy (within 30 days of starting home health care, n=65) resulted in a 48% overall reduction (p≤ .0001) in home care length of stay in patients with a Stage III or IV pressure ulcer vs. the group who received V.A.C.® Therapy after the 31st day of home health care.2 NOTE: Specific indications, contraindications, warnings, precautions and safety information exist for KCI products and therapies. Please consult a physician and product instructions for use prior to application. Rx only. ©2010 KCI Licensing, Inc. All trademarks designated herein are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. DSL#12-0188.TWC (Rev. 8/12)

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inmemoriam preceded by weeks of detailed preparations that he tackled with infinite patience — shouldering the vast majority of the work. During that time, the Medicare director of coverage policy changed three times, and we had to reinvent our discussions with each change in leadership. In the final meeting with CMS, with the issue of coverage for diabetic foot ulcers hanging in the balance, I lost my composure with an official. Bob stepped in, handling the situation with aplomb.That was one of his great qualities — that he could say the right things and keep his head when others, like me, lost theirs. I always respected Bob, but in that moment I developed a deep and abiding admiration for him. An excellent scientist who was a joy to conduct research with, Bob could cultivate any basic idea into a fully articulated creative project. I may be a university professor, but I always learned a lot from Bob. The “ask Bob” option was usually the most thorough way to understand any topic pertaining to wound care or hyperbaric medicine. For the last 10 years, Bob was employed as chief medical officer for Praxis and Diversified Clinical Services (most recently with Healogics). Many hyperbaric medical physicians owe their passion for the field to the training they received through his courses. Bob set the bar with the clinical practice guidelines he developed and the passion with which he conveyed them.

THE ‘OTHER’ BOB Despite his extensive, busy career, Bob somehow managed to devote his time and energy to Bible School programs (along with his wife Karen) for hundreds of churches in Mexico and to medical mission trips to Malaysia, Kenya, and Nigeria. He’s survived by his wife of 36 years, his brother Mark, his sister Judith, his mother Alice, and his daughters: Amy Lemire, Lesley Davies, and their families. In lieu of flowers, the family encourages contributions to Mexico Missions, First Baptist Church of The Woodlands (11801 Grogans Mill Road, The Woodlands, TX, 77380); Barry University, School of Podiatric Medicine (11300 NE 2nd Ave., Miami Shores, FL, 33161); andVolunteer Services at the University of Texas MD Anderson Cancer Center (1515 Holcombe Blvd., Houston, TX, 77030). Bob was devoted to his family, his patients, his colleagues, and the field of wound care and hyperbaric medicine. He will be greatly missed by all of us. He had a strong faith in the Lord, and this Bible verse seems a fitting tribute to him: “I have fought the good fight, I have finished the race, I have kept the faith. Now there is in store for me the crown of righteousness, which the Lord, the righteous judge, will award to me on that day — and not only to me, but also to all who have longed for his appearing.” (2 Timothy 4:7-9) Perhaps we can take comfort and encouragement from Bob’s example to continue to run, with courage, the race set before each of us. n Caroline Fife, co-editor of TWC, chief medical officer at Intellicure Inc., cfife@intellicure.com

TODAY’S

EDITORIAL BOARD FOUNDING EDITORIAL BOARD MEMBERS CO-EDITOR OF TODAY’S WOUND CLINIC Caroline Fife, MD, FAAFP, CWS CO-EDITOR OF TODAY’S WOUND CLINIC Dot Weir, RN, CWON, CWS Christopher A. Morrison, MD, FACHM, FCCWS Valerie Sullivan, PT, MS, CWS Kathleen D. Schaum, MS

EDITORIAL BOARD MEMBERS Andrew J. Applewhite, MD, CWS, UHM Leah Amir, MS, MHA Desmond Bell, DPM, CWS Trisha Carlson, MSN, MBA-HCM, RN, CWCN Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA Moira Hayes, MHA, RRT, CHT Cathy Thomas Hess, BSN, RN, CWOCN Harriet Jones, MD, BSN, FAPWCA Robert S. Kirsner, MD, PhD Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA Pamela Scarborough, PT, DPT, MS, CDE, CWS Susie Seaman, NP, MSN, CWOCN Tere Sigler, PT, CWS, CLT-LANA Pamela G. Unger, PT, CWS, FCCWS Randall Wolcott, MD, CWS

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83 General Warren Boulevard, Suite 100, Malvern, PA 19355 © 2012, HMP Communications, LLC. All rights reserved. Reproduction in whole or in part prohibited. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of HMP Communications, LLC, the editorial staff, or any member of the editorial advisory board. HMP Communications, LLC is not responsible for accuracy of dosages given in articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement or approval of the products or services advertised or of their effectiveness, quality or safety. HMP Communications, LLC disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Content may not be reproduced in any form without written permission. Reprints of articles are available. Contact HMP Communications, LLC for information.HMP Communications, LLC (HMP) is the authoritative source for comprehensive information and education serving healthcare professionals. HMP’s products include peer-reviewed and non-peer-reviewed medical journals, national trade shows and conferences, online programs and customized clinical programs. HMP is wholly owned subsidiary of HMP Communications Holdings LLC. Discover more about HMP’s products and services at www.hmpcommunications.com.

September 2012 Today’s Wound Clinic®

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businessbriefs Call to Action:

Start Preparing for ICD-10-CM Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information.HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader

s you probably know, the deadline for implementation and compliance with ICD-10-CM was originally set for Oct. 1, 2013. Recently, the US Department of Health and Human Services (HHS) announced a proposed rule that would delay the compliance date until Oct. 1, 2014. The public comment period has since closed while HHS reviews the feedback. What does this delayed date mean for wound care providers? You have been granted additional time to: • ensure that you have a solid documentation improvement program, • analyze your data for areas of concern, • audit your medical records, • examine your workflow, • communicate with your computer vendors, • revise your forms and templates, and • integrate new documentation requirements into practice – regardless of work setting. Do not waste this precious gift of extra preparation time. The US Centers for Medicare & Medicaid Services (CMS) has predicted that most health systems and professional practices needed 4 years of preparation time. If you have not begun, you now have 2 years to accomplish the many steps involved in the implementa-

tion of ICD-10-CM.The purpose of this article is to provide a basic understanding of the coding and documentation changes that you must start to implement.

Benefits of ICD-10-CM Conversion One of the main benefits of ICD-10CM is that disease classifications will be consistent with current clinical practice and medical technology advances. The new classification codes will be very granular, which means the level of specificity will greatly improve.Numerous new codes will represent more specific anatomic sites, etiologies, comorbidities, and complications, and they will improve the provider’s ability to demonstrate severity of illness. For instance, the new feature of laterality is directly built into the new codes:separate codes will distinguish right, left, and bilateral, where needed. The increased granularity will provide better analysis of disease patterns and outbreaks of disease. Additionally, the US will be using the global diagnosis coding system. The current ICD-9-CM system consists of approximately 13,000 codes and is running out of numbers. The new ICD10-CM system is expanding to approximately 68,000 codes and has flexibility for expansion. ICD-9-CM codes have 3-5 characters that are numeric, with the exceptions of the “V” codes (factors influencing healthcare),“E” codes (external causes of injury),and“M”codes (neoplasm morphology) that begin with a single letter.The new ICD-10-CM codes have 3-7 characters that are alphanumeric. To take advantage of ICD-10-CM, all medical professionals, coders, billers, etc. must have a basic understanding of the differences between ICD-9-CM and ICD-10-CM (eg, code formats, code descriptions, and

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ICD-10-CM coding instructions. Many seminars pertaining to these basics are offered by numerous vendors, professional associations, and payers. All wound care professionals should attend ICD-10-CM workshop(s) that pertain to their medical specialty(ies).

Preparing for ICD-10-CM Conversion

Clinicians should form task forces with representation from all disciplines involved in wound care that own responsibility for full implementation of ICD-10-CM. Teams should meet frequently over the next 2 years to create and implement “to do”lists that include tasks such as reviewing computer systems, documentation forms, documentation habits, and auditing data (forms and processes) as well as educating providers on how to meet the specificity of the ICD-10-CM coding system.The task force may choose to conduct an operations assessment that will identify where the various components of the medical record come from, who generates the medical record information and documentation, and who updates the electronic health record (EHR) templates and software or paperbased medical record documents.Reviewing current documentation practices,especially of the most frequent diagnoses seen, and improving providers’ documentation is the most important ICD-10-CM preparation step.This documentation improvement process will benefit your practice immediately and assist with preparation for increasing the specificity of ICD-10-CM diagnosis coding.With proposed ICD-10CM codes frozen until 2014 implementation, the documentation practices that providers implement today will still be in effect 2 years from now.

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businessbriefs Currently, various payers (including RecoveryAudit Contractors and Office of the Inspector General) are auditing wound care practices for inadequate justification of medical necessity. Therefore, scrutinizing medical record documents and the diagnostic information contained on each document is crucial in beginning a documentation improvement process.Reviews should also be done for all documentation requirements set forth by JCAHO, department of health, medical staff rules and regulations, and documentation requirements in pertinent Medicare National Coverage Decisions (NCDs) and Local Coverage Determinations (LCDs). CMS has released several NCDs while Medicare Administrative Contractors have released numerous LCDs pertinent to wound care services, procedures, and products (ie, many NCDs and LCDs state that wound care physicians must document failed conventional wound care before Medicare will cover the use of more advanced procedures and products. When reviewing the diagnosis driven medical record, ask yourself the following questions: • Where can you find historical information about your patients? • Where can you find referrals from the referring physicians? • Where can you find discharge summaries? • Where can you find the most current problem lists? • Where can you find consultation reports? • Where can you find outpatient medical records? Are they electronic or are they paper-based? • What processes are in place to obtain past medical records if the patient doesn’t bring them to the first appointment? • Does the EHR carry forward diagnosis information from visit to visit inappropriately? • Are your registrars, rather than your physicians, currently assigning the ICD-9-CM codes that are used on the claim forms? Performing self-audits of documentation practices, departmental/institutional

processes, actual coding, and denied claims will identify problem areas where the medical team should focus its attention. If coders are available to assist with selfaudits, ask for a frequency listing of diagnosis codes seen in practice.These are the codes for which one should learn the new ICD-10-CM codes and the documentation required to support them. When reviewing common diagnosis codes, pay particular attention to any “not otherwise specified” and “unspecified codes.”These codes usually end in .8 or .9. Just as their description infers, these unspecified diagnoses should be areas of concern. If documentation in the medical record was not specific enough to assign an ICD-9-CM code, accurate coding of any diagnosis in the ICD-10-CM system won’t be possible. Start training now to prevent queries, which coders dislike requesting and physicians dislike receiving. If providers focus on improving documentation for diagnoses treated, they will have more robust medical justification for their work in the ICD-9-CM system and they will prevent long delays in processing claims when transitioning to ICD10-CM. When ICD-10-CM begins, coders will not be able to process claims for medical records that do not contain specific documentation that leads to a specific diagnosis code. In these cases, coders will have to stop the claim and query the provider for more specific documentation. Education of all wound care professionals who document in the medical record will be key to developing excellent documentation habits that support specific ICD10-CM codes.To accomplish this, identify a practice “champion” who is passionate about ICD-10-CM and is willing to educate others on how to properly document.

Points to Ponder for Conversion All providers will likely uncover many areas that need to be addressed in order to smoothly transition to the ICD-10-CM. When combining the wound care clinician’s responsibility for providing highquality care as patients move throughout the healthcare continuum along with the required documentation to support medical necessity via ICD-10-CM, we all must

understand the importance of maintaining a longitudinal medical record that is easily accessible for all providers and payers. As you begin ICD-10-CM conversion, consider the following: • Plan to run ICD-9-CM and ICD10-CM simultaneously for some time because bills that aren’t dropped prior to conversion will need to use ICD-9CM. Providers will need to communicate with their payers as to how long dual systems need to be run. In addition, pre-ICD-10-CM claims that must be re-billed will require ICD-9-CM codes. • Budget for outside services that will most likely be needed to assist with the conversion. • Evaluate the efficiency of information flow from registration to billing and from billing to remittance notice. • Continue to use CPT® (Current Procedural Terminology) coding for procedures and evaluation/management visits performed by physicians, podiatrists, non-physician practitioners, therapists, hospital-based outpatient wound care departments, and ambulatory surgery centers. • Anticipate that multiple ICD-10CM codes may be required to fully describe some medical conditions while other ICD-10-CM codes may represent multiple medical conditions in a single code. • Assess skill levels of individuals performing the coding function. • Train the entire professional wound care team on comprehensive, specific documentation. • Monitor your clinical documentation improvement program and communicate your successes and opportunities for improvement to the entire staff. • Develop a query program that requests clarification regarding non-specific documentation from providers. • Use metrics to show each medical professional’s documentation improvement. • Review how claim denials are currently handled. • Determine if additional staff will be required to handle ICD-10-CM conversion. continued on page 32

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ESTABLISHING A CARE CONTINUUM

IN RURAL AMERICA

In North Central Louisiana, one provider is leading a dedicated team of clinicians to improve wound care delivery. Frank Aviles Jr., PT, CWS, WCC, FACCWS, CLT

ealthcare providers face many challenges related to patient care, regardless of one’s location or setting. However, there are significant ongoing issues that those providers working in rural communities continue to experience and that are exceedingly piquing the attention of organizations and providers on a national scale. Defined as any population or territory outside an urban area by the US Census Bureau, “rural” communities are determined by the population density of any terri-

tory located outside a Census Bureaudefined urbanized area or urban cluster. This includes populations of fewer than 50,000 and may include an area with 1-999 people per square mile. Statistics indicate that less than 10 percent of physicians practice in rural areas,1 and family physicians who practice in rural areas need to possess a broad range of skills in providing comprehensive care to residents due to the lack of physician specialists.2 According to the National Rural Health Association (NRHA),

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the number of specialists per 100,000 people for rural areas is 40.1 compared to 134.1 in urban areas. While only 20 percent of the US population lives in rural areas, higher rates of chronic illness and poor overall health are found in these communities when compared to urban populations.3 Rural residents are typically older, poorer, and have fewer physicians to care for them.They are also nearly twice as likely to die from unintentional injuries other than motor vehicle accidents, www.todayswoundclinic.com

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ruralhealth according to the NRHA. Additionally, Medicare reports that its patients with acute myocardial infarction who are treated in rural hospitals are less likely than those treated in urban hospitals to receive recommended treatment. This article will illustrate some of the challenges that providing healthcare in rural America presents and how taking a proactive role can improve the overall continuity of care in one’s community.

LAGGING RURAL RECRUITMENT

It has long been estimated that the US will continue to experience an increasing shortage of healthcare professionals that will place increasing constraints on those who practice, particularly in the field of wound care, due to increased number of patients who live with chronic wounds. These challenges are expected to be especially evident for those in rural areas where the employee pool is already limited. A study from the Center for the Health Professions at the University of California, San Francisco, reports the shortage is a chronic problem in low-income and rural areas and that residents in these areas could encounter more difficulties in accessing care. (This doesn’t apply strictly to physicians and nurses.) By 2014, the Association of Academic Health Centers anticipates 82,000 nationwide openings will exist for dental hygienists, while other estimated deficits include 43,000 for occupational therapists, 72,000 for physical therapists, 40,000 for physician assistants, and 57,000 for respiratory therapists. When considering the potential effects of healthcare reform on our present economic situation, one might wonder how rural healthcare staffs are going to care for an increased number of patients when considering the compounded challenges of caring for an aging US population. As an experienced provider in a rural setting, I face issues on a daily basis related to workforce shortages, increased patient caseloads, more work hours, increased physical and emotional stress, difficulty

finding staff coverage for personal time off, and even finding the time to attend continuing education (CE) sessions. Then, there are times when census is down in a rural facility. While this might seem to present a relief, it’s often the opposite as facilities find themselves forced to decrease their workforce. In particular, rural areas are not typically known for enticing new graduates, established practitioners, or industry specialists to relocate. Pay is usually less and establishing a practice is difficult due to lower populations, to name a few reasons. In addition, for those with families there’s difficulty in a spouse finding work and limited school choices for children. Another obstacle experienced by providers is secondhand — many rural residents have serious transportation and income barriers. I’ve known local patients who’ve had to decide to go through with an amputation because they could not afford gas, as treatment meant driving 120 miles round trip daily to a facility, or because they had difficulty finding someone to take them to an out-of-town facility. (Some small towns do not have taxis.)

A PERSONAL JOURNEY

In 2001, I moved to Louisiana from Florida, eventually settling long-term in Natchitoches, a city located in the North Central part of the state, in 2006. Most people can’t pronounce our city (na’-ka-tosh), but as locals, we believe we were put “on the map” when Steel Magnolias filmed here in 1989. A quaint, little town that’s also famous for its annual Christmas festival and considered to be a great place to retire, Natchitoches is a place where everyone knows each other, where many people live in historic plantation homes, and where there’s not much industrialization. Store selections are limited and are highlighted by a Walmart and what might be considered a strip mall. We have a total of about 25 physicians in town, including two general surgeons, a cardiologist, and an orthopedist surgeon with hospital privileges. We have

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a dermatologist and a podiatrist available, but only on an outpatient basis. And if someone becomes emergently ill or requires specialty care they can expect to travel 60-80 miles if a specialist isn’t in town. While in Florida, I worked in a hospital that housed more than 1,000 beds in a city that was home to 240,000 people, and we had many resources available to assist the well-being of our patients. Today, I’m in a small town of 18,000 people with a 70-bed hospital. Relocating was something I knew would not be an upward move for my career, but I felt a calling to “do the right thing” as a provider and be with my aging in-laws. I consider my situation similar to that of my father, Frank, who always worked hard, likewise cared for his in-laws (my grandparents), and always seemed to demonstrate a calm and collective demeanor in times of stress. Being born in Puerto Rico and raised in Florida from the time of age 10, my initial “culture shock” out here was fairly superficial — my car would often get stuck in mud in my front yard after a rainstorm. But when I soon accompanied my wife’s (Anne) family on a crawfishing trip and they warned me to “watch out for gators and to swim quickly back to the tractor if I got bitten by a snake (without dropping any crawfish mind you) in order to have adequate time to make it to the hospital,” the severity of the healthcare situation really began to take hold. In time I’d learn to purchase waders, boots, a shotgun, a four-wheeler, and an antivenom kit, and I’ve since watched educational programs on how to tame wild animals when confronted. I’ve come to really enjoy the small-town atmosphere and the people in my community, and it’s a great place to raise a family, as Anne and I have done with our daughters Hannah, Sarah, and Laura. But this on its face hasn’t necessarily solved my dilemma of constantly trying to improve local healthcare for others. In 2006 I took a job at an acute care hospital in town. At the time, I was fairly

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ruralhealth certain that it was the only healthcare job in my field (physical therapy) available. The facility did feature a long-term acute care (LTAC) center that staffed a wound specialist who ultimately relocated. The hospital system also was involved with supplying therapy services to a local nursing home and two outpatient clinics (one in town, the other 30 miles away). As such, my role quickly expanded when these facilities lacked staff due to vacations, participation in CE sessions, and/or vacancies. Before long, I worked more hours and more weekends than I had ever planned. Knowing that we have minimal staff in the region, I always curtail my personal and professional schedule to be available to accommodate patients if other providers are out of town.

FORMING AN EDUCATION CONTINUUM

In 2009, I launched a wound care project that has established and maintained a wound care continuum with the support of my supervisor and a team of healthcare professionals. Through a dedicated team effort we educate patients and providers on evidence-based practice, bringing education to rural areas that integrates “best” practice with clinical practice and improves communication between clinicians through the continuum. We inform others of available innovative dressings, introduce advanced modalities, and have developed a network of wound care health professionals in and out of town. Our goals and the action plan consist of the following: Improving wound care knowledge. For community members, we speak/educate at church organizations, National Council of Aging meetings, hospital forums, and community health fairs. For healthcare professionals, we’ve partnered with a CE company to bring 2-3 yearly courses to town. This allows clinicians to get educated without worrying about staff coverage and travel expenses. Personally, I set a goal of attaining multiple wound care credentials in order to improve my own education and be more valuable

as a resource. I now teach CE classes for companies at their request. We’ve also introduced wound care vendors and products to the area. They bring samples and allow us to use new products, and assist in educating others (in a strictly enforced non-biased manner). We’ve also been known to host dinerbased educational meetings with participants who travel from nearby towns and well-known speakers who fly in. Our reach has grown to provide for a company in Lafayette via live presentations, monthly webinars, and referral sources. I’ve also started my own consulting/education business (Cane River Therapy Services) that provides facilities and organizations with specific training on various wound care subjects (as requested) as well as staff coverage when a therapist is needed. Centralizing communication. Since we do not yet have a dedicated wound center (though we are getting closer to that reality), we maintain open lines of communication through my employment within the LTAC center, local outpatient therapy clinics, acute hospital, nursing homes, and home health agencies. I’m on everyone’s speed dial and have become the communications “middle man” in those instances when a physician or therapist isn’t within reach. Improving use of dressings and introducing advanced modalities. We conduct research with the nursing homes and home health agencies to learn which products they’re carrying and which are producing better outcomes. Through the assistance of vendors we’ve also improved educating staff on proper dressing use and patient compliance. We’ve also trialed (and now use) low-frequency ultrasound devices, and the results have been phenomenal in improving our outcomes, especially in areas with limited resources. Developing the expert network. I’ve recruited a group of “physician champions”— Dr. William A. Ball Jr., MD, FACS; Dharam Gurwara, MD; Kerry Thibodeoux, MD, FACS; Gary

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Mazzanti, MD; and others — who serve specific local regions to help foster timely communication to area staff and vendors to keep the continuum strong.

DEDICATED TO RURAL COMMUNITY

Over the years, I’ve been offered many job opportunities with better working conditions and more career growth, but did not pursue them as I am quite fulfilled working with my colleagues and in my community. More recently, I’ve also had the chance to improve outcomes within my facility and beyond. In order to earn enough of a consistent living to support my family and remain a “full time” healthcare provider in this region that I’m so passionate about, I spend my “off days” lecturing, seeking out per-diem time as best I can, picking up “odd jobs” such as home painting and remodeling, and continuing to grow my side business. Yes, rural areas present challenges to our committed healthcare providers, which, in turn, creates a difficult environment to attract new, younger providers. The effort can be daunting and exhausting at times, but rural healthcare overall needs increased attention in order to provide the necessary, timely, and appropriate care to our aging population. Thanks to the help of a great team of local and more distant clinicians we’ve been successful in improving communication and care. n Frank Aviles, Jr. is clinical director of therapy services and wound specialist at a rural long-term acute care facility; owner, instructor and consultant for Cane River Therapy Services; and instructor for the Academy of Lymphatic Studies. He can be reached at 318-228-5056 or at crts@cp-tel.net.

REFERENCES

1. R osenblatt R, Hart, LG. Physicians and rural America. West J Med. 2000;173 (5):348-351. 2. American Academy of Family Physicians. Rural Practice, Keeping Physicians In. Accessed online at www.aafp.org/online/en/home/policy/ policies/r/ruralpracticekeep.html. 3. C hang J, et al. More Choices, Better Coverage: Health Insurance Reform and Rural America. Accessed online at www.healthreform.gov/reports/ruralamerica/ ruralmorechoicesmorecoverage.pdf.

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Wound Care on the go ‘Portable ER’ Allows Physician to reinvent house calls John A. Sterba, MD, PhD, FACEP

Editor’s Note: The terms “Portable ER,” “Community-Based Portable ER,” and “Physician House Calls” are trademark-pending and used as defined by the author,1-2 who conducts house calls as a board-certified acute care specialist of emergency medicine credentialed to treat children and adults. The author initially developed, tested, and evaluated concepts referenced in this article while in the military (far removed from any hospital). Much of the field-testing and evaluation occurred while he was on active duty with the US Navy Experimental Diving Unit, Panama City, FL, as an operational undersea warfare medical officer in the US Navy Medical Corps. The current portable ER discussed was conceived, developed, tested, and evaluated overseas in 19893-5 at Thule Airbase, Greenland, and upon the High Arctic ice pack in the North Pole region. Based in part on its successful use, the final medical, surgical, and pharmacy inventory for the military Portable ER was published and authorized for overseas use by US Navy healthcare providers.3-5

here are few images more associated with the nostalgic, bygone era of medicine than a physician making “house calls” throughout a community. Presently, the theory of “patient centeredness” has become a cornerstone of modern healthcare reform. A system that once was completely focused on “what was best for the patient” is now completely aimed at doing what is “financially best for the physician and the business of private and government-run insurance companies.” However, our current medical practice known as Physician House Calls using our Community-Based Portable ER (Portable ER) represents a transition back to excellence in which medical and surgical (med/surg) services such as advanced wound care can be conveniently performed in any setting, but are particularly valuable in rural and suburban communities. Through this proven

method of care, healthcare providers can combine old-fashioned home visits with modern medical technology to achieve patient-centered advanced wound care with substantial insurance reimbursement. Our private practice provides expert med/surg care for patients living with most wound care issues, including pressure ulcers; arterial and/or venousinsufficiency ulcers; diabetic or neuropathic ulcers; skin tears, abrasions and avulsions; simple, complicated, and complex lacerations; and thermal or chemical burns. This article will discuss the development and concepts of the Portable ER and how it relates to improved mobile wound care outcomes and business.

History of the Portable ER

The Portable ER,1-2 which is noted for its use in offering advanced wound care, was successfully implemented in

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the U.S. (in the Greater East Aurora Area of Western New York State) on Feb. 16, 2009.While home health agencies provide non-surgical patient care to patients who meet the requirements of homebound status, the Portable ER allows physicians to make house calls to provide med/surg services such as mobile wound care to patients who do not qualify for home health agency care and/or who may be lacking adequate transportation, finances, insurance, and/or family support (or a private primary care physician). After leaving the military in 1990, I redeveloped and expanded the usage of a Portable ER system I had developed for the US Navy to provide better med/surg care to civilians during missionary international emergencymedicine trips. The civilian Portable ER was redesigned, tested, and evalu-

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ruralhealth

ON THE CALL AGAIN: John A. Sterba, MD, PhD, FACEP, arrives with numerous med/surg kits at his disposal. Used with permission. ated to best care for patients during and recovering from natural disasters and the devastating results of terrorism and anarchy. In my current position as the medical and scientific director of Saved by Grace Ministry Inc. (East Aurora, NY), serving since 1998 along with my wife and co-founder Janice E. Sterba, I use the Portable ER for the private medical practice of emergency medicine and urgent care medicine, including advanced wound care.

Making The Physician House Call

When a phoned-in request for physician services is made, each patient is triaged for appropriateness. More often than not, rapidly determining the chief complaint and history of present illness (HPI) during the call determines whether an onsite visit is appropriate within about four minutes’ time. Occasionally, certain requests lead to a referral to a primary care provider (PCP), other med/surg specialist, or local therapist (eg, when a request for general child vaccination is made or if a physi-

cian referral is specifically requested). A growing request is actually for us to become a PCP with no current chief complaint, in which case patients are referred to local PCPs accepting new patients. Approximately 5-10 percent of our phoned-in requests are true med/surg emergencies. These complaints are quickly and expertly triaged, and patients are instructed to call 911. Upon accepting a patient’s request for a house call, the physician selects the needed hand-carried med/surg kits and portable dispensary cabinets (PDCs) among the 87 within the Portable ER dispensary and travels in a mid-sized, fuel-efficient car to the home. All kits and PDCs are stored securely in a private residence that’s humidity and temperature-controlled. (For Portable ER inventory, see references1-2 and sidebar on page 21). Assessment of nutritional considerations such as body mass index, ideal body weight, and skin fold thickness are quickly determined during a house call. These indices help iden-

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tify protein/calorie malnourishment in patients living with slow-healing wounds and prompt better nutritional recommendations and more successful follow-up care. The Portable ER also provides blood-chemistry services. Total serum protein and albumin can be measured and printed by a portable point-of-care POC lab using the Centers for Medicare & Medicaid Services’ (CMS) Clinical Laboratory Improvement Amendments-Waived Comprehensive Metabolic Profile (CMP) panel. Nutritional assessment with printed CMP lab results can be obtained and explained in fewer than 15 minutes during a house call. From our ongoing Institutional Review Board-approved clinical study that measures patient convenience of house calls, the time from ordering a blood chemistry test until lab results are explained is 13.8 minutes. (+ 5.2 minutes. SD, n = 45 patients). Two sensitive blood chemistry tests (pre-albumin and serum transferrin) that are useful to assess current nutritional status must be drawn at the home and taken to a lab.

Finances of Physician House Calls

Our private medical practice is credentialed as a humanitarian, public charity, nonprofit corporation. Taxdeductible donations are accepted and contributions, insurance-required co-pays, and insurance checks are used to help care for other patients in great need in our community and to buy med/surg supplies or medications. Patients without insurance are never turned away — donations are encouraged in these instances. In addition, Saved By Grace Ministry Inc. has provided med/surg care to more than 4,300 patients during seven civilian medical missions from 2004-08, settings in and out of hospitals in West Africa,6 Central America, and the Caribbean Basin.7-8 Our insurance billing is approximately 25 percent of the cost for similar services billed from the hospital-based ED. Of all patients seen during house calls, 91 percent are not clinically indicated to

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ruralhealth be sent to the ED. The remaining nine percent require to be transported to the ED for further lab/radiology studies, but are rarely admitted. The most productive and economical way we recruit patients is through inexpensive advertisements printed in local newspapers that are often clipped and saved by patients in the event of needed care. Some people have actually made “referrals” by seeing our ads. Likewise, we’ve produced refrigerator magnets and business cards, which are freely passed along after house calls as well as during community events such as health fairs, festivals, and parades. A brochure that lists all portable med/surg services and POC laboratory services has been mass-produced using an at-home publishing program and shared throughout the local community, and has been warmly received by local pharmacies, private physician offices, laboratories, nursing homes, businesses, and churches. We also frequently provide demonstrations at community service organizations and events such as Kiwanis and Lions clubs and senior citizen centers. Furthermore, we provide hands-on training through inservices that fully equip interested healthcare providers to establish their own portable services. By providing house calls, the Portable ER has decreased inappropriate overuse of the local ED and has grown financially through the enthusiastic endorsement from patients and family members as well as through support from area physicians (including primary care, emergency, and med/surg specialists on staff at local hospitals), insurance companies, Medicare, and Medicaid. Additionally, local church, civic leader, and public support have been very strong.9-16 CMS allows reimbursement for “home visits” wherever a patient may live, including in the private home (Place of Service [POS] 12), temporary lodging (POS 16), nursing facility (POS 32), skilled nursing facility (POS 31), and homeless shelters (POS 04). Since patients are not seen or treated at a physician’s office, com-

Online Exclusive: What’s in a Portable Advanced Wound Care Kit? Find out what Dr. John Sterba brings with him on house calls to care for wound care patients. Visit www.todayswoundclinic.com and search for this article.

mercial zoning is not needed for physicians to conduct house calls. General liability insurance is also not needed by the physician because the Portable ER is not a “mobile clinic.” Patients are not treated inside a vehicle, obviating the need for related insurance or licensing typically required by the department of health. However, physicians must maintain their own medical liability insurance policy for their specialty. (Part-time practitioners, ie fewer than 20 hours per week of actual patient contact time who don’t perform acute care, see lower premiums.) Recently, we successfully petitioned and were advised that National Government Services Medicare B will begin paying for all integumentary procedures, including surgical debridement and other procedures for physician house calls that are conducted in a patient’s private home or temporary residence. Our advanced wound care during house calls is documented on paper and electronically. In conclusion, Physician House Calls using the Community-Based Portable ER provides faster, better, and cheaper care — including advanced wound care — when compared to the hospital-based ED or urgent care facility. n John A. Sterba can be reached at 716655-6854 or physicianhousecalls@roadrunner.com. For more information, visit www. physicianhousecalls.org. Caroline Fife, MD, FAAFP, CWS contributed to this article.

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References

1. S terba JA, Sterba JE. Textbook of equipping for disasters, sheltering at home,Third Edition. Saved by Grace Ministry Inc. 2012. 2. S terba JA, Sterba JE. Textbook of equipping for disasters, sheltering at home,Third Edition (Kindle edition). Saved by Grace Ministry Inc. 2012. Published electronically by amazon.com for Kindle Books (eBooks) on June 30, 2012. www. amazon.com. 3. Sterba JA. Arctic cold weather medicine and accidental hypothermia. Navy Experimental Diving Unit (Panama City, FL). Report 2-90. 1990. 4. Sterba JA. Thermal problems, prevention and treatment. In: Bennett PB, Elliott DA (Eds.). The Physiology and Medicine of Diving, Fourth Edition. W.B. Saunders Co., Ltd., London. 1993. 5. Sterba JA. Arctic cold weather medicine and accidental hypothermia. In: Underwater Construction Team Arctic Operations Manual, NAVFAC P-992. Naval Facilities Engineering Command, Alexandria VA. 6. Sterba JA. Kamakwie Wesleyan Hospital: an assessment of needs report. Center for Sports Therapy Research Inc., East Aurora, NY. 2004. 7. S terba JA. Mission guide: Cachón and Barahona Province, Dominican Republic. Saved by Grace Ministry Inc., East Aurora, NY. 2006. 8. Sterba JA. Mission guide: Caribbean and Central America. Saved by Grace Ministry Inc., East Aurora, NY. 2009. 9. Sterba provides in-home emergency medical care. East Aurora Advertiser. 2009. 10. Testimonial: Dr. John Sterba says PennySaver ad works. PennySaver. 2010. 11. EA’s Sterba makes old-fashioned house calls. East Aurora Bee. 2011. 12. Physician house calls provide free labs at home & at work. PennySaver. 2011. 13. Free point of care labs offered in East Aurora. Sterba can do blood tests onsite. East Aurora Advertiser. 2011. 14. Brodsky L. Healthcare Delivery Models are Changing - a New Model as Practiced by “Dr. John.” Accessed online at http://thebrodskyblog.com/?p=2623. 15. House call services is growing. Sterba offers care at home for local residents. East Aurora Advertiser. 2012. 16. Physician house calls: faster, better, and cheaper than your doctor (PA,NP) or urgent care or the over-crowded ER. East Aurora Advertiser. 2012.

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TELEMEDICINE:

THE KEY TO OPENING THE DOOR TO WOUND CLOSURE IN RURAL COMMUNITIES? A Georgia hospital network experiences successful outcomes. Harriett B. Loehne, PT, DPT, CWS, FACCWS

he goal of any wound care provider is to offer the best-known and bestavailable standard of care, regardless of setting or location. As such, all patients should receive care in a timely, efficient, cost-effective manner — and that care should never fail to be consistent across the healthcare continuum. When integumentary specialists are unavailable, as is often true in clinics found in rural communities, providing optimal wound care becomes more challenging as more patients often must be transported long distances in order to see a specialist. Today, however, wound care clinicians are realizing a new solution to this problem and are achieving better wound management outcomes through the use of telemedicine programs that offer patients and providers alike electronic access to remote specialists who can assist in the delivery of care for chronic, nonhealing wounds. The benefits of telemedicine service also are seen on the financial side in that it fuels economic development within the rural areas it’s used. Business prospects consider healthcare a key factor when deciding on location, and the opportunity to be seen by specialists, whether integumentary or otherwise, is significant. At Archbold Medical Center (AMC) in Thomasville, GA, the use of telemedicine has allowed staff to augment our overall physical presence in the five surround-

ing counties we serve by providing expertise in smaller, rural communities. In essence, the “path” to advanced wound management has been repaved.

A NEW UNDERTAKING

Staff at AMC began utilizing telemedicine in 2004 through a grant from the Rural Health Initiative of Georgia, a project aimed at improving availability of technology to rural healthcare providers in an affordable manner that’s sponsored by the WEDI (Workgroup for Electronic Data Interchange Foundation) in conjunction with Mercer University School of Medicine and Morehouse School of Medicine. In 2007, AMC joined the Georgia Partners for TeleHealth (GPT), a statewide network that aims to increase access to healthcare through innovative use of technology. As a “hub and spoke site” for tele-health, AMC (a network of one main hospital, three affiliate rural hospitals, three subacute swing bed hospitals, three nursing homes; a psychiatric hospital; a rural specialty clinic; an urgent care facility; a hospice program; two visiting nurse associations and a home health agency) is considered an information “hub.” As a “hub,” AMC houses a computer server that stores patient records and other valuable information. AMC also serves as a “specialty site and as a patient-present-

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ing site, referring patients to other consultants within the telemedicine network while providing consultations for patients outside of AMC. Telemedicine and teleradiology specialists providing remote consults at AMC include a dermatologist, a psychiatrist, a surgeon, a podiatrist, a neurosurgeon, a cardiologist, an interventional cardiologist, and a physical therapist (PT) who’s also a certified wound specialist (CWS®). The majority of our consults are provided by the dermatologist, psychiatrist, and, PT, who, according to GPT, is performing more consults than any other clinician in Georgia. Telemedicine is available in two forms: “real time” (which features interactivity on the part of both the patient and the clinician) and “store-andforward” (the transmission and storage of photos and/or data for future use — not as expensive, easier to use and maintain, and the most common type used today1). Equipment needed to conduct the service includes a computer and applicable software, specialized cameras and video equipment, high-speed telephone lines, and encryption technology. Real-time telemedicine offers live consulting, which requires a transmission network with an image-sending station. The software also displays diagnostic data, lab values, etc.

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ruralhealth Telewound Documentation

Wanna Logue, RN, certified telehealth coordinator, operates the telehealth system at Archbold Medical Center. Photo courtesy Archbold Medical Center.

Conducting Tele-Wound Care

As the clinical educator of wound management my role includes providing monthly patient visits to affiliate facilities (all located within an hour’s drive of each other) to conduct consults, complete rounds, provide formal and informal education, and to treat complex wounds, among other services. Detailed weekly reports of all wounds and skin tears are sent to me by network nursing home staff, and all facilities that I visit are required to send me photo documentation of each wound I treat on a weekly basis. All information is stored on a dedicated telemedicine laptop. At John D. Archbold Memorial Hospital (JDAMH), our flagship hospital, I host live telemedicine integumentary clinics monthly (along with a surgeon) to allow rural facilities to have their patients seen without having to be transported many miles to the physician’s office or the wound center. Local physicians can also request clinic consults, either new or followup. Prior to a consult, I receive the patient’s history, wound culture reports, and wound assessments. Information

and equipment they are to have for the physician at the clinic includes current prealbumin, lab values, and wound measurements; previous wound assessments (including photo documentation); patient charts; swabs for probing the wound; and forceps. The most common type of integumentary telemedicine in use today, according to the GPT, is the store-and-forward method, which can serve in a stand-alone capacity or be used in conjunction with real time. Using the Internet, this method provides regular monitoring through photo documentation. Consults or follow up can be done from any location, and the program stores data and automatically places photos in individual patient folders listed chronologically. Files are archived, allowing for continuity of care and follow up. Each folder also contains a demographics form, a referral form, and all images. If desired, recent labs, history and physical, and related procedures can be scanned in, summarized, organized, and displayed in a meaningful way.2 This also allows an intervention for prevention of pressure ulcers and assists in the continuum of care.

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There are templates included within the program that assist in the documentation of the exam/consult. Terms can be keyed immediately into the system by the physician (and/or allied clinician) and printed. A consultation form can be sent for a live visit. Email and phone can be used for comments following the visit. By going to the computerized documentation and checking integumentary documentation, it is easy to coordinate Braden scores with facility protocols (for pressure ulcer prevention interventions), and to check prealbumin labs to monitor protein nutrition. Wound status can be monitored regularly while appropriate dressings and management can be determined. At AMC, we are fortunate in that all facilities utilize the same products and essentially the same policies and protocols, which are adapted to facility type. It’s also easy to monitor whether physicians’ orders are being followed, pressure ulcers are being correctly identified and staged, and interventions are being conducted appropriately. In 2000 a study by Kobza et al discussed telemedicine and chronic wounds in the home care setting. Outcomes showed improved healing rates, decreased healing times, decreased number of home health visits, and decreased number of hospitalizations related to wound complications. The latter is an important factor in current reimbursement and regulatory issues. Kobza concluded that telemedicine is a viable option for delivering quality, costeffective care to chronic wound patients in the home care setting.3 Reimbursement is covered by insurance in Georgia through the Rural Health Initiative, which states if insurance covers being seen in person, it must cover telemedicine if conducted in one of several sites. The originating sites covered by Medicare include the office of the physician or practitioner, hospital, critical-access hospital, rural health clinic, federally qualified health center, skilled nursing facility, hospital-based dialysis center, and community mental health center.4 There is a 5 percent

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ruralhealth bonus if the patient resides in a federally designated “physician shortage area.” The originating site also receives a site fee.5 As of Jan. 1, 2010, a skilled nursing facility can use C0406-G0408, which previously was just for the inpatient hospital setting. Modifiers GT and GQ may be used.6 Only real-time telemedicine consults are reimbursable under Medicare. Store-andforward does not meet the Centers for Medicare and Medicaid Services’ definition of telemedicine. However, it is reimbursable by Medicaid under section 1905 of the Social Security Act in 27 states.7 The annual net cost savings to Medicare is estimated to be $2 billion-$4 billion.8 The future looks bright for telemedicine and our rural communities. The American Recovery and Reinvestment Act of 2009 calls for $2.5 billion to invest in infrastructure and tools for promotion of telemedicine in real time.9

ADVANTAGES/DISADVANTAGES

Development of a suitable telemedical system in the wound care field can have a significant effect on a community as well as tertiary referral patterns and hospital admission rates.10 With the advent of telemedicine for wound management, advantages include the ability to schedule emergent and new-patient consults more quickly, with shorter wait times for the patients/residents (hereafter referred to as “patient”). Additional advantages for clinicians include reduced travel and associated costs as well as patient-centered care, more streamlined care planning, easier wound management, and decreased costs. Advantages of telemedicine for patients are many:They can stay with their local physician, which also is a physician’s advantage; travel to see a specialist is not necessary; and cost savings are seen in not having to call an ambulance and/or go to an emergency department (ED). Major hospitals see a decrease in ED visits, which can result in an increase in patient census, in areas where telemedicine is utilized. Of course, there are a few disadvantages of the telemedicine system for an integumentary consult. There’s an obvious inability to palpate the wound or peri-

wound tissue and an inability to determine the depth of the wound and any undermining by palpation. There’s also an inability to detect odor, but all noted disadvantages can be overcome by having the PT/PT assistant/integumentary nurse who’s with the patient provide descriptions and measurements. However, a study by Dobke et al indicated that telemedicine consultations provide accurate chronic wound assessments. Between 2003 and 2005, 120 patients in a variety of settings were seen by a surgical wound specialist via telemedicine and subsequently via direct consultation. Settings included long-term care, skilled nursing, and home care. Store-and-forward was used, with only photos and the plan of care being emailed. Upon physical examination, only two cases (1.67 percent) showed a surgeon change the previously established diagnosis and management plan, demonstrating validity of telemedicine consultation.11 A 2003 small pilot study12 published by Halstead et al compared wound assessment of spinal cord injured patients via telemedicine and live exam. A plastic surgeon reviewed laptop images of 20 wounds among 17 individuals, then assessed the patient and wound live. The percent of agreement was: • 95 percent need to change the management of the wound • 95 percent need for referral • 85 percent satisfaction for making treatment decisions • 80 percent need to obtain additional information A significant study published in 2006 by Hofmann-Wellenhof et al addressed the feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers. Forty-one ulcers of different origin in 14 patients were included. During the initial inperson visit the leg ulcers were assessed and classified, and underlying diseases were noted. Follow-up visits were done by home health nurses. Digital images of the wound, periwound tissue, and relevant clinical information were transmitted weekly via a secure website

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to an expert at the wound care center. These experts provided assessment of the wound status and therapeutic recommendations. In 89 percent of 492 teleconsultations the quality of the images was sufficient or excellent. The experts reported being confident giving recommendations. Treatment modalities were changed or adapted in onethird of the consultations. A significant decrease in visits to the physician or the wound center was noted.13 A “bonus” benefit of a real-time system is its effectiveness in educating healthcare providers in rural areas while online with the specialists. Likewise, it is efficacious in educating family and caregivers. Hofmann-Wellenhof et al published an article stating that effective learning can be fostered in a telemedicine network, and in some respects is more effective than it would be in face-to-face caregiving. They determined the education component of telemedicine contributes to quality healthcare.14 Another important function of the real-time system is its use to conduct inservices and lectures. As many as four facilities can participate simultaneously on screen.

TELEMEDICINE’S REACH

Even the lay public is learning more about the value of telemedicine and wound management. In 2009, Parade magazine published an article about Rafael Grossmann, MD, at Eastern Maine Medical Center, that featured the use of telemedicine in his work as an expert in burn injuries. Grossmann compared 59 emergency telemedicine consults with telephone consults. With telemedicine, unnecessary transfers were practically eliminated and medical errors were reduced by 75 percent. This also saves unnecessary transfers to other hospitals and saves the family journeys.15 n Harriett B. Loehne is clinical educator at Archbold Center for Wound Management & Hyperbaric Medicine,Thomasville, GA. References can be found online at www.todayswoundclinic.com.

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TWCnewsupdate School of Medicine Establishes Warriner Scholarship Barry University’s School of Podiatric Medicine will be using a $25,000 donation by school dean Jeffrey Jensen, MD, and his wife Celia to launch the Dr. Robert Warriner III Scholarship for Research in Neuropathy Prevention at the Paul & Margaret Brand Research Center in Miami Shores, FL.The scholarship will provide research scholarships to podiatric medical students researching neuropathy prevention. Warriner, who passed away in August, was recognized among the nation’s foremost physicians and researchers in hyperbaric medicine and wound management. Donations can be made by visiting www.barry.edu/giving/donate. Select the “In Memory Of ” option, then type “Dr. Robert Warriner III Scholarship Fund” in the designation box that appears. n

TWC Board Member Guides Wound Management Program Today’s Wound Clinic board member Harriet L. Jones, MD, BSN, FAPWCA, associate professor of medicine,is among staff at University of Mississippi Medical Center (UMMC), Jackson, MS, that will soon provide care in the facility’s first comprehensive wound management clinic. According to facility officials, more space is needed at UMMC to care for the number of patients coming in. Plans have reportedly been approved to renovate an area in the University Physicians Pavilion for a comprehensive wound management center expected to open next year.The program also will include tele-wound care. Jones received her MD from UMMC School of Medicine in 1998 and completed residency training in internal medicine at UMMC in 2001. After she completed a fellowship in infectious diseases, she joined that division as an assistant professor of medicine and surgery in 2003 and began an outpatient antimicrobial service program in the division of infectious diseases. n

California Hospital Launches Area’s First HBOT Nonprofit Healdsburg District Hospital (HDH) recently began offering what’s reportedly the only hyperbaric oxygen therapy (HBOT) service available in Sonoma County at Northern California Wound Care (NCWC). According to HDH officials,NCWC has exceeded the national healing rate for wound care treatments,consistently healing 95-97 percent of wound cases, since its inception in 2010.The wound care department is led by Daniel Rose, MD, medical director of HDH’s wound care services. Approximately 15 percent of patients seen in the clinic qualify for HBOT.With numerous“centers of excellence,”HDH serves as the first-line inpatient, outpatient, and emergency care facility for 60,000 residents of Windsor, Healdsburg, Geyserville, Cloverdale, and surrounding areas of northern Sonoma County. n 26

SPOTLIGHT ON: Technology MOBILE APP FOR DIABETES CARE A new mobile application designed for healthcare providers who care for people living with type 1 diabetes has been released by Indianapolis-based pharmaceutical company Lilly. The Lilly Glucagon Mobile App teaches the proper use of glucagon for injection through simulated practice and helps caregivers understand the drug’s role in diabetes management by better preparing them on how to use glucagon in the event of an emergency. The app was developed with input from healthcare providers and people with diabetes, and can be used by diabetes educators and school nurses as a teaching tool, Lilly officials said. Components of the app also include visual and audio emergency instructions.

PORTABLE NPWT DEVICE EquinoxO2 Medical LLC, Smithfield, RI, has introduced a new pump system for ambulatory patients who require negative pressure wound therapy (NPWT).The HALO XP NPWT pump system is a lightweight, portable system that combines advanced technology with easy-to-use features, officials said. It’s expected to provide an affordable option to patients and healthcare facilities. n

Partnership Brings Wound Care Training Healthcare staff at Tri-City Medical Center, Oceanside, CA, is teaming with Massachusetts-based biotech company Organogenesis Inc., to receive wound care training. The preceptor program will be conducted at Tri-City’s Center for Wound Care and Hyperbaric Medicine in Carlsbad, CA. According to a report by the North County Times of Escondido, CA, Tri-City is one of just two centers nationwide that partner Organogenesis has chosen for the training program. n

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TWCnewsupdate Hospital Expansion Opens New Wound Center A nearly $2.1 million facility expansion at Munroe Regional Medical Center (MRMC), Ocala, FL, will be used to expand the wound care treatment program. According to the Star-Banner newspaper of Ocala, wound care services are expected to be operating in a new outpatient location by January in Cala Hills, FL. Most wound patients currently receive wound care on an inpatient basis, a program that reportedly doesn’t offer hyperbaric oxygen chambers. The new facility will. “I think it’s a great opportunity for the community to get a comprehensive wound care program,” said Lon McPherson, MD, Munroe’s vice president of medical affairs and chief quality officer. Munroe will reportedly take over the lease of a nearly 5,100-square-foot building that houses Ocala Health System’s Wound Care & Hyperbaric Services. Munroe will not take over the business, according to the report. Officials estimate the program will be profitable by its second year and generate a net income of about $150,000 annually by year three. Estimates also see the facility serving about 300 patients per year, with each patient making about 10 visits. Officials said that by taking over a building already fitted as a wound care center, MRMC will save about $95,000 in startup costs. MRMC is owned by the state-sanctioned Marion County Hospital District and is overseen by trustees appointed by the county commission.The trustees currently lease the hospital to Munroe Regional Health System Inc. The hospital board and district trustees voted unanimously to give hospital executives permission to lease the property, according to the report. Under the plan, Nautilus Healthcare Management Group, Newport Beach, CA, will manage the wound center for Munroe. By the second year of the three-year lease, Munroe will pay Nautilus $589,000 for its management oversight and onsite personnel, according to the report. Munroe also will pay another estimated $263,000 in overhead costs during the second year of operation. n

Net Health Acquires Wound Care Strategies Officials with Pittsburgh, PA-based Net Health Systems, a provider of clinical information systems for the wound care industry, have announced the purchase of Wound Care Strategies, Inc., (WCS) developer of the TPS™ electronic medical record software for wound care clinicians. According to officials, the combined companies support the clinical information systems of more than 50 percent of US wound clinics. With the transition, WCS founder and president, and Today’s Wound Clinic editorial board member, Cathy Thomas Hess, BSN, RN, CWOCN, will join Net Health as vice president and chief clinical officer, bringing more than 25 years of experience in wound care. “Cathy’s experience in various acute care, long-term care, and outpatient wound clinics is impressive and positions Net Health to offer our clients an expanded base of knowledge,” said Anthony Sanzo, Net Health CEO. “We’re excited to have this industry veteran on our team as we continue to grow.” Financial terms of the transaction were not disclosed. n

Medicaid Decision Could Affect Wound Care in Georgia A decision by Georgia Gov. Nathan Deal to reject expansion of Medicaid prescribed by the Affordable Care Act would leave thousands of the state’s poorest residents uninsured and threaten hospitals that were counting on new income from these changes. According to the Atlanta Journal-Constitution, Deal’s decision has set off widespread anxiety among hospital officials and patient advocates. “I have diabetics who lose legs because they do not get wound care or get to see a podiatrist,” said Carole Maddux, CEO of Good Samaritan Health & Wellness Center in Pickens County. The federal healthcare law calls for anyone younger than 65 with an income up to 133 percent of the federal poverty line to be eligible for Medicaid starting in 2014. Under the law, the feds would pay 90-100 percent of the cost of the Medicaid expansion, which would add 650,000 state residents to the program’s rolls, according to the report. Georgia officials project its share of the expansion would reach $4 billion over 10 years. According to the report, the governor might agree to expand Medicaid if the federal government gave the state a “block grant” of money and the freedom to tailor the program — neither of which is currently in the law. Failing to expand Medicaid would be most costly to hospitals that care for uninsured Georgians. About one in five state residents is reportedly uninsured. According to Kevin Bloye, spokesman for the Georgia Hospital Association, state hospitals currently provide about $1 billion in uncompensated care. n 28

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SAWCSPRING 速

The official meeting site of the Association for the Advancement of Wound Care

AAWC

May 1-5, 2013 Colorado Convention Center Denver, Colorado www.sawcspring.com

Check us out on:

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Where Wound Clinic Professionals Go For Answers The Symposium on Advanced Wound Care Spring and Wound Healing Society (SAWC Offering up to 30.5 credit ho Spring/WHS) meeting is the urs for wound ca re premier multidisciplinary wound clinicians! care program and is the largest annual gathering of wound care clinicians in the United States. More than 2,000 physicians, podiatrists, nurses, therapists, and researchers are expected to attend the 2013 SAWC Spring/WHS meeting. No other wound care conference offers the level of education, the number of quality sessions, and world-renowned educators each year that clinicians at wound care centers have come to expect at SAWC Spring/WHS. Key Sessions For Clinicians At Wound Care Clinics • Demystifying the Use of Compression • How to Address Complications of Diabetic Foot Ulcers • Assessing the Latest Evidence on HBOT • Wound Care in Special Populations: From Our Smallest to the Largest • Healthcare Reform: What it Means for You • MicroRNA in Wound Repair and Regeneration: A New Paradigm • Telemedicine: What is its Role in Wound Care? • Managing Complex Wounds in the Acute Setting • Strategies For Healing In Palliative Wound Care • Making Wound Centers Run Smoother – A Panel Discussion Learning Objectives • Identify common wound-related skin conditions and their management. • Discuss advances in wound-related physiology, pathology, epidemiology, prevention, assessment, and management. • Evaluate the effects of research on the future of patient care. • Translate scientific data and emerging research knowledge to clinical practice. • Implement the latest best-practice strategies to prevent and manage pressure ulcers. • Explore the wide range of treatment modalities for wound care, including new and emerging therapies. • List the medical and surgical treatment of wounds • Provide optimal healthcare delivery through improved understanding of sites of service and payment schema. • Review current evidence- and consensus-based guidelines and describe how guidelines can be developed into practical algorithms that are used in everyday wound care.

To register for SAWC Spring/WHS in Denver, visit www.sawcspring.com

Intended Learners This conference is designed for physicians, nurses, physical therapists, researchers, podiatrists, and dietitians involved in wound healing or wound care issues. Accreditation Information This activity has been planned and implemented by North American Center for Continuing Medical Education, LLC (NACCME) and the Wound Healing Society (WHS) for the advancement of patient care. North American Center for Continuing Medical Education, LLC (NACCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Physicians: NACCME designates this live activity for a maximum of 30.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 6.25 AMA PRA Category 1 Credits™ for WHS Day 1 4 AMA PRA Category 1 Credits™ for the pre-conference 17.25 AMA PRA Category 1 Credits™ for the main conference 3 AMA PRA Category 1 Credits™ for the post-conference Nurses: This continuing nursing education activity awards 6.25 contact hours for WHS Day 1, 4.0 contact hours for the pre-conference, 17.25 contact hours for the main conference, and 3.0 contact hours for the post-conference. Provider approved by the California Board of Registered Nursing, Provider Number 13255 for 6.25 contact hours for WHS Day 1, 4.0 contact hours for the pre-conference, 17.25 contact hours for the main conference, and 3.0 contact hours for the post-conference. Podiatrists: North American Center for Continuing Medical Education, LLC (NACCME) is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine. This program is approved for 6.25 contact hours for WHS Day 1, 4 contact hours for the pre-conference, 17.25 contact hours for the main conference, and 3 contact hours for the post-conference. Dietitians: North American Center for Continuing Medical Education, LLC (NACCME) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 6.25 continuing professional units for WHS Day 1, 4 continuing professional education units for the pre-conference, 17.25 continuing professional education units for the main conference, and 3 continuing professional education units for the post-conference for completion of this program. CDR Accredited Provider #HM001 Level 3 Synthesis Level Physical Therapists: North American Center for Continuing Medical Education, LLC (NACCME) will apply for pre-approval accreditation in California, Florida, Louisiana, Ohio, and Texas, which require pre-approval. If you practice in another state, please consult its PT board. Note: The following sessions are non-accredited: WHS Session F: Concurrent Mini-Symposia WHS Session G: Organogenesis talks WHS Session H: Animal Model Roundtable Requirements for Credit: To be eligible for documentation of credit for each session attended, participants must participate in the full activity and complete the online general survey and the online evaluation form for each session by June 5, 2013. Complete the forms at http://www.myexpocredits.com/naccme . After completing the forms, participants may immediately print documentation of credit. Copyright ® 2012 by North American Center for Continuing Medical Education, LLC. All rights reserved. No part of this accredited continuing education activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from North American Center for Continuing Medical Education. ADA Statement: North American Center for Continuing Medical Education complies with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call 609-371-1137.

Robert Kirsner, MD, PhD

Dot Weir, RN, CWON, CWS

Cancellation Policy: Please note the cutoff date for cancellation is March 19, 2013. All cancellations must be received in writing and postmarked by that date. Full registration (less a $75 processing fee) will be refunded only to cancellations received in writing before the above date. No refunds will be issued after March 19, 2013 — without exception. Registrations are transferable at any time.

Vice Chairman and Stiefel Laboratories Professor Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine Miami, FL

Osceola Regional Medical Center Kissimmee, FL

For registration or general information, call 800-854-8869.

SAWC Chairpersons

SAWCSpring2013_2pageAd_TWC.indd 3

*Information contained herein is subject to change without notice.

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Apligraf® Essential Prescribing Information Numbers in parentheses ( ) refer to sections in the main part of the product labeling. Device Description: Apligraf is supplied as a living, bi-layered skin substitute manufactured from cells processed under aseptic conditions using neonatal foreskin-derived keratinocytes and fibroblasts with bovine Type I collagen. (1) Intended Use/Indications: Apligraf is indicated for use with standard therapeutic compression in the treatment of uninfected partial and/or full-thickness skin loss ulcers due to venous insufficiency of greater than 1 month duration and which have not adequately responded to conventional ulcer therapy. (2) Apligraf is indicated for use with standard diabetic foot ulcer care for the treatment of full-thickness foot ulcers of neuropathic etiology of at least three weeks duration, which have not adequately responded to conventional ulcer therapy and extend through the dermis but without tendon, muscle, capsule or bone exposure. (2) Contraindications: Apligraf is contraindicated for use on clinically infected wounds and in patients with known allergies to bovine collagen or hypersensitivity to the components of the shipping medium. (3, 4, 5, 8) Warnings and Precautions: If the expiration date or product pH (6.8-7.7) is not within the acceptable range DO NOT OPEN AND DO NOT USE the product. A clinical determination of wound infection should be made based on all of the signs and symptoms of infection. (4, 5) Adverse Events: All reported adverse events, which occurred at an incidence of greater than 1% in the clinical studies are listed in Table 1, Table 2 and Table 3. These tables list adverse events both attributed and not attributed to treatment. (6) Maintaining Device Effectiveness: Apligraf has been processed under aseptic conditions and should be handled observing sterile technique. It should be kept in its tray on the medium in the sealed bag under controlled temperature 68°F-73°F (20°C-23°C) until ready for use. Apligraf should be placed on the wound bed within 15 minutes of opening the package. Handling before application to the wound site should be minimal. If there is any question that Apligraf may be contaminated or compromised, it should not be used. Apligraf should not be used beyond the listed expiration date. (9) Use in Specific Populations: The safety and effectiveness of Apligraf have not been established in pregnant women, acute wounds, burns and ulcers caused by pressure. Patient Counseling Information: VLU patients should be counseled regarding the importance of complying with compression therapy or other treatment, which may be prescribed in conjunction with Apligraf. DFU patients should be counseled that Apligraf is used in combination with good ulcer care including a non-weight bearing regimen and optimal metabolic control and nutrition. Once an ulcer has healed, ulcer prevention practices should be implemented including regular visits to appropriate medical providers. Treatment of Diabetes: Apligraf does not address the underlying pathophysiology of neuropathic diabetic foot ulcers. Management of the patient’s diabetes should be according to standard medical practice. How Supplied: Apligraf is supplied sealed in a heavy gauge polyethylene bag with a 10% CO2/air atmosphere and agarose nutrient medium. Each Apligraf is supplied ready for use and intended for application on a single patient. To maintain cell viability, Apligraf should be kept in the sealed bag at 68°F-73°F (20°C-23°C) until use. Apligraf is supplied as a circular disk approximately 75 mm in diameter and 0.75 mm thick. (8) Patent Number: 5,536,656 Manufactured and distributed by: Organogenesis Inc. Canton, MA 02021 REV: December 2010 300-111-8 References: 1. Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290-295. 2. Data on file, Organogenesis Inc. 3. Apligraf® [package insert]. Canton, MA: Organogenesis Inc; 2010.

businessbriefs continued from page 9 •E valuate how the transition will affect your EHRs or paper records. Do forms and electronic screens need to be revised? • Review and revise, if necessary, the organization of medical records. • Train registration personnel on how to obtain medical records from referring providers and on how to locate, print, and file national coverage decisions, local coverage determinations, and medical policies in a convenient place for everyone’s use. Establish a routine forum for communicating coverage changes to staff and patients. Organogenesis_PI_0211.indd 1 • Review and revise, if necessary, policies and procedures that are affected by ICD-10-CM conversion. n Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corporation, Plainsboro, NJ, and an American Health Information Management Association-certified ICD-10-CM trainer. She can be reached at 609-936-2265 or at donna.cartwright@integralife.com.

32 September 2012 Today’s Wound Clinic®

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Advertiser’s Index Derma Sciences.................................................. Cover 2 Healthpoint Biotherapeutics........................................11 Intellicure.....................................................................15 KCI ................................................................................5 Matrix Health Services LLC..........................................7 Medela..........................................................................3 MiMedx Group ...........................................................23 2/1/11

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Net Health Systems...................................... 27, Cover 3 Organogenesis Inc. ...................................... 32, Cover 4 Sechrist Industries Inc. .......................................... 16,17 Total Wound Care Solutions........................................13

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The pressure is off. Off of you, off the wound, off the patient.

Total Contact Cast System vs Other Off-Loading Modalities 3

TCC-EZ® eliminates those problems. It’s a best-in-class off-loading system providing: • A simpliﬁed casting process • Signiﬁcantly reduced application time • Greater patient comfort • Same optimal off-loading outcomes

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50.4

70% 60% 50%

33.5

65.0%

58.3%

40%

30%

20% 10

10% 0%

Total Contact Removable Casting Cast/Walker

Mean Days to Complete Healing

Proper off-loading is one of the most important factors in managing diabetic foot ulcers. Total contact casting (TCC) is the one modality that has demonstrated optimal healing rates - in multiple controlled studies - and is recognized as the Gold Standard of Care in off-loading. But concerns regarding tissue damage, complex and time consuming application, and patient comfort have discouraged physicians from using TCCs.

Percent of Wounds Completely Healed

88% of wounds managed with total contact casting heal in 43 days.1 No other DFU therapy can say that.

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TCC-EZ® offers a one-piece, roll-on, woven design that simplifies the application process while reducing the potential for causing additional tissue damage. The result is a process that takes about ¼ the amount of time of traditional casting systems2,3 and a product that gives greater patient comfort. All while providing gold standard off-loading for optimal clinical outcomes. For a TCC-EZ® product demonstration, please contact your local representative or visit our website.

Quicker application. Greater comfort.

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www.dermasciences.com or call 800.445.7627 1.

Bloomgarden, ZT; American Diabetes Association 60th Scientific Sessions, 2000. Diabetes Care 24:946-951, 2001.

Bohne, G; Cost Effectiveness and Implementation of an Easy to Apply Total Contact System for Diabetic Grade 2 Neuropathic Foot Ulcers in Multi Physician Clinic. CSASWC Conference, 2009.

Shah, S; The Economics of Total Contact Casting. SAWC Spring Conference, April 2011.

Armstrong, et al; Diabetes Care, June 2001.

Scan this QR code now with your smart phone to view educational information and product videos on the TCC-EZ website.

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6/18/12 1:24 PM

Cut out the paper. Why run to the printer and fax machine every time you need to place an order for V.A.C.® Therapy? With WoundExpert® simply:

1) Click the V.A.C.® Therapy button 2) Complete the form 3) Transmit it directly to KCI for fulfillment. No need to re-enter data–WoundExpert® automatically populates the information for you and checks form compliance, decreasing errors and saving you time. Learn more at www.WoundExpert.com or contact KCI Express® Support at 800-275-4524, ext. 65080.

©2012 Net Health Systems, Inc. WoundExpert is a trademark of Net Health Systems, Inc. KCI, V.A.C., and KCI Express are registered trademarks of KCI Licensing, Inc., its affiliates and/or licensors. Used by permission. DSL#11-0241.C (4/11)

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9/7/12 9/6/12 11:03 9:35 AM AM

After 4 weeks of failed conventional therapy— Rethink the Wound. Think Apligraf®.

Healing Wounds. Healing Lives. Act now for fast and complete healing of diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs).1-3 • Choose the ONLY bioengineered, bilayered, living cell–based product3 • Apligraf is the ONLY treatment indicated for both DFUs and VLUs3 • FDA approval for DFUs as early as 3 weeks3 • FDA approval for VLUs as early as 4 weeks3 • Frequent reassessment and reapplication of Apligraf as needed can signiﬁcantly improve the speed of healing and incidence of complete wound closure in DFUs and VLUs1-3

For information on support programs and tools available from Organogenesis Inc., call 1.888.HEAL.2.DAY (1.888.432.5232—Option 3) Please see accompanying essential prescribing information, or visit www.Apligraf.com for complete prescribing information

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