Clinical

Accurately Assessing Pressure Ulcers

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (npuap.org).

Pressure ulcers are costly, painful and are often perceived as the result of poor quality care.  The Center for Medicare and Medicaid Services has included pressure ulcer risk assessment and implementation of prevention protocols in the OASIS-C. Home health agencies that fail to identify patients at risk are missing an important step to preventing pressure ulcers that occur under the care of the agency.

Tools for Outcome Measurements

Pressure ulcer prevention begins with risk assessment.  In the  OASIS-C item M1302, The Center for Medicare and Medicaid (CMS)  asks that patients be identified with or without a formal pressure ulcer screening tool. Agencies should choose a validated pressure ulcer screening tool. The Braden Scale (Bergquis & Frantz, 2001) has been validated with home care populations, but it is not the only validated tool available. The Norton and the Waterlow Scale are also good alternatives. What is more important is accuracy and consistency in use. This can only be accomplished through staff education.

Once the risk assessment is completed, implementation of  pressure ulcer prevention measures should be based on the information obtained. The Braden Scale has a set of measures correlated to the risk identified (www.bradenscale.com). Many clinicians use the overall Braden score as a starting point for deciding risk. However, when sub-scale scores such as mobility, incontinence or shearing are triggered, it is just as important to address these with appropriate prevention measures.

Several factors impact pressure ulcer prevention in the home. Taking these factors into prevention planning will improve an agency’s ability to avoid pressure ulcers in their patients.

Accurately Assessing Pressure Ulcers

“What is a Patient-Centered Medical Home?”

You might have heard of a patient-centered medical home a concept that is taking off throughout the county — but do you know what it means?

The concept combines the old-fashioned care you used to get from your family doctor with high-tech centralized monitoring and coordination of your healthcare records.

Highmark, Inc. recently established more than a dozen medical home pilot practices in central Pennsylvania, adding to the number of health systems testing the concept. Penn State Milton S. Hershey Medical Center, Pinnacle Health System and Holy Spirit Health System all have family health centers that are acting as medical homes. The main problem, however, is that most people don’t understand what a medical home is — and, no, it’s not a nursing facility.

To understand the concept and how it’s being implemented, The Patriot-News talked to Dr. Andrew Bloschichak, senior medical director at Highmark, and Dr. William Bird, vice chairman of patient care, Department of Family and Community Medicine at Hershey Medical Center. In a nutshell, here are the facts:

Defining a medical home

It’s a primary care practice, led by a physician (usually an internist or family doctor). It brings together a team of medical professionals to coordinate and personalize all of your medical care. The “home” refers to the doctor’s office.
Your physician is your primary contact. He or she directs your medical team and provides comprehensive care for you, arranging care with other health care professionals when needed.

When the American Academy of Pediatrics created the medical home concept in 1967, it meant the place that a child’s medical records were kept. The concept has now expanded and has really come to the forefront in the past few years as part of the efforts to reduce health care costs.

Medical homes are not like insurance HMOs with a gatekeeper. You are free to see any specialist you select. Additionally, some insurance companies, including Highmark, have restructured physician reimbursement to allow your doctor to spend more time with you.

Medical home team

The team, captained by your physician, is made up of nurses, nurse care managers, medical assistants, office support staff and, in some instances, pharmacists and/or social workers, all of whom work together to oversee your well-being. Their job is to keep you healthy by making sure you’re on track with your medicines, appointments and medical tests. They also will advise you on your diet or ongoing treatment and educate you in ways to stay well, recuperate or deal with a chronic health problem. It’s all about communication.

In the case of the pilot practices started by Highmark, clinically trained nurse care managers are provided to jump-start each pilot practice and coordinate the social work aspect in evaluating patients and developing plans of care. For example, they work with patients who transition from the hospital to home, or home to a nursing facility, answering questions and making sure follow-up appointments are kept.

Technology is key

Through a centralized electronic records base, your complete medical history, with all test results, are stored in one location that can be accessed by your medical team to coordinate your care.

Centralized electronic medical records allow the team to review a patient’s medications, allergies and comprehensive health care notes, as well as when the last time the patient was seen by a doctor. This eliminates duplication of tests, alerts the staff to a needed appointment or test, and gives the physician a better long-range picture of your health.

Physicians also use the data to compare treatment results to national results, ensuring quality of care. In the Highmark pilot project, data will be collected to review the outcome and assess the project’s success.

Centralized data helps create registries

A registry is a systematic collection of data on specific health characteristics, gathered from a centralized database. The data is broken down into diseases, which enables the physician to look at the entire practice.

Many practices implementing medical homes are starting out by using the registries to track diabetic patients. Bird said the type 2 diabetes registry used by Hershey Med allows him to “look at all the patients in my medical home and find those with high blood sugars; anyone who hasn’t seen me in a while; and who should be seen. I can refer these names to my team to schedule appointments or to contact about tests they should have.”

How this helps doctors

Bird said the medical home is a philosophy of care that asks a lot more of the primary care doctor, but also covers all the bases for care through a team approach.

Hershey joined the Highmark pilot project last summer after having taken part in two other pilot projects.
“About four years ago, Penn State Hershey Medicine decided that the medical home concept was a good model for our 14 primary care practices,” Bird said. “At that time there was no additional reimbursement for doctors from the insurers, but it was the right move for us. The Highmark pilot has helped tremendously because of funding and accountability.

“The most important piece of this is technology,” he said. “Fortunately, at Hershey, we have a great IT resource. Centralized information is now available to help avoid duplication of services and to maintain the current status on each patient.”

How this helps patients

Under the previous system, “if a patient didn’t show up for an appointment, then he or she wasn’t cared for,” Bird said. “We were re-active, not pro-active. Now, with our medical home practice, we’re able to make the best use of time.”

For patients, communication is key. “There is always someone available to address his or her concerns,” Bird said.  And patients are welcome to communicate via emails or phone calls when they have a question, which can help eliminate unnecessary office visits.

Goals

The Highmark pilot project will hopefully demonstrate lower re-admission to hospitals, better chronic care management, happier doctors and better-satisfied patients. The hope is that once the pilot is over, medical homes will have the resources to continue with the extended professional staff.

“With positive outcomes, we’ll be able to prove our value to the insurer/payer, which is incentive for this to work,” Bird said. “It’s the future of adult primary care for our country.”

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