A Collaborative Approach To Diabetes Care September 27, 2013 Charlotte, NC

1. Maximize Insurance Reimbursement with New CMS Regulations to Drive Profitability in the Management of Diabetic Foot Ulcers A Collaborative Approach To Diabetes Care September 27, 2013 Charlotte, NC Janette Dietzler-Otte MSN, RN, CWS, COCN

2. St. Anthony’s Medical CenterSt. Louis, MO

3. Objectives • Develop a comprehensive plan of care to optimize healing and reimbursement • Understand how a strong relationship between all levels of care can impact readmission rates. • Understand how maximizing insurance reimbursement with new regulations can drive profitability

4. Challenges: Managing Diabetic Patients • Complexity of Wound Healing • Supply availability and costs • High cost to treat ulcers • Reimbursement and staying abreast of changes • Compliance • Communication

5. Goals • Increase healing rates • Decrease days to heal • Decrease amputation rates • Decrease quit rate • Optimize reimbursement

6. Best Practice • Comprehensive evidence based protocol for wound care is essential • Attention to criteria for advanced wound care modalities

7. Evidence based Standardized to fit needs of wound clinic’s population Address First Visit Needs Follow Up Visit Needs Be aware of Payer Develop Protocols/Guidelines

8. Utilization of Advance Wound Care Modalities/Protocol-Impact on Healing Outcomes Protocol Revised Protocol Developed

9. Sample Protocol FIRST VISIT LABS • CBC, CMP. ESR, Pre-Albumin, HGB-A1C(Diabetics only) • Tissue culture on admission (Wounds > 4 weeks old) PROCEDURES • Ankle/Brachial Index- LE and foot wounds (Toe pressures for diabetics) RADIOLOGY • XRAY-R/O OSTEOMYELITIS (Wound on bony prominence) or foreign body • BONE SCANor MRI (Physician’s discretion) WOUND CARE • Use advanced wound care products • Offload all wounds • Elevation and Compression as indicated for patients with PVD Follow-up Visits • Visits Weekly for the first 6-8 weeks utilizing advanced wound care products. • LABS as needed • Monitor blood sugars regularly on all diabetics • Tissue biopsy if no improvement in 4 weeks or wound fails to respond to conventional treatment • Sharp Debridement weekly as needed

10. Use of Advanced Wound Care Across the Continuum • Best practice • Available in different levels of care • Insurance reimbursement

11. Insurance Reimbursement • Starts before patient is seen • Verify patient eligibility and information • Obtain prior authorization • Obtain information about co-pay, co-insurance and deductible

12. Coding and Charging • Building a comprehensive Chargemaster • Proper billing of CPT and diagnosis codes in the outpatient setting, DRG’s in the inpatient setting • Documentation is essential to ensure correct coding • Know what billing and reimbursement rules apply in your geographic region and place of service. • Know what laws apply to your specialty.

13. Common Advanced Wound Care Modalities • Negative Pressure Wound Therapy • Bioengineered Skin Substitutes/Flaps/Grafts • Hyperbaric Oxygen Therapy • Dressings

14. Patient Compliance • Important to get patient “buy in” • Contract on admission can be helpful • Follow through on what is spelled out in contract • Refer non compliant patients back to PCP

15. SamplePatient Care Agreement As a part of your treatment here, the physician may make recommendations in the following areas: • Offloading: As directed by your physician, you will need to relieve pressure from your wound while it is healing; this may include using special shoes, braces, crutches and/or a wheelchair, specialty bed or mattress. • Medication: Take all prescribed medications as ordered. Advise the staff of any changes in your medication since your last visit. • Wound Dressings: Application of your wound dressings as directed by your Physician is your responsibility. You are also responsible for notifying us if you have any questions or problems regarding your dressings.

16. Treatment and Care of your wound requires your participation in the program! Therefore you will be responsible for: • Keeping your scheduled appointments. If you are unable to keep your appointment it is your responsibility to notify the office at least 24 hours before your scheduled visit. Failure to keep your scheduled appointments may result in charges for a missed visit and/or discharge from the program. • Maintaining good Health Practices: Diet, exercise (and exercise restrictions) and if diabetic, being in control of your diabetes. • Stop smoking! • Control Edema (swelling): Many of our patients are prescribed compression wraps and/or stockings and/or compression pump therapy. These must be used as directed. • Wear any ordered offloading devices as instructed. For example, a special shoe or boot. • Compliance with the recommended treatments is vital to the success of your treatment plan. If you fail to comply with the physicians recommendations you may be discharged from the program.

17. Impact of Poor Transition of Care Fragmented Responsibility In a recent survey 42% of hospitals report “things fall between the cracks when transferring patients from one unit to another” Agency for Healthcare Research and Quality on Patient Safety Culture Survey 2007

18. Quality Impact 19.6% of Medicare patients were readmitted in 30 days 34% were readmitted within 90 days Hospital readmissions within 30 days accounts for $15 billion of Medicare spending. Medicare Payment Advisory Commission June 2007

19. Poor Communication Causes Confusion regarding patient condition and appropriate care Duplicate testing Medication Errors Delays in diagnosis Inconsistent patient monitoring Lack of follow through on referrals National Transitions of Care Coalition

20. Ways to Improve Transition of Care • Electronic Medical Records • Expand the role of the pharmacists in respect to medication reconciliation • Accountability for sending and receiving care • Increase the use of case management and professional care coordination • Develop and implement performance measures to improve transition of care. • Empower patient and family National Transitions of Care Coalition

21. Developing a Process to Maximize Reimbursement • Prior Authorization Process • Checklist to ensure appropriateness use of expensive products • Discuss with patient co-pay and obtain written agreement to pay • Develop charge-master to capture all charges. • Audit Explanation of Benefit’s (EOB) to ensure reimbursement www.envcap.org

22. Example only

23. Case Study 1 Patient is a 64 year old male • Type II Diabetes • Neuropathy • Charcot deformities • 2 year old ulcer on the plantar surface of foot. • Patient told he would need an amputation

24. Challenges • High risk for amputation • High risk for infection • Needs aggressive offloading • Needs aggressive Glycemic control • Needs adequate oxygenation • Needs optimal nutrition www.making-sense.org/page.php?page=1

25. Treatment Plan • Debridement • Bioengineered skin substitute weekly x 8 • Offload site with AFO boot • Diabetes education www.careplans123.com

26. First Application • Pre-application of bioengineered skin substitute • Wound measurement: 1.6 x 1.8 x 0.4cm

27. 3 Weeks Later • Bioengineered Skin Substitute 3rd Application • Wound measurement: 1.3 x 1.8 x 0.2 cm

28. 8th Week Last Bioengineered Skin Substitute Applied • Wound measurement: 0.2 x 0.4 x 0.2 cm

29. 9th Week Post Initiation of Skin Substitute Applications Wound Healed

30. Therapeutic Impact • Healed wound • Days to heal 63 • Patient satisfaction “excellent” • Cost to treat = $12,308 • Amputation cost = Avg $38,077/procedure plus risks associated with procedure, risk of increased mortality by 50%. Arran Shearer, et al (2003) www.petergmcdermott.com

31. Case Study 2 75 year old female with a 3 year-old ulcer and: • Diabetes • Neuropathy • Patient told needs amputation

32. Challenges • High risk for amputation • High risk for infection • Needs aggressive offloading • Needs aggressive Glycemic control www.letsliveforever.net

33. Treatment • Debridement • Bioengineered skin substitute weekly x 8 • Offloaded with Cam Walker

34. 4 Weeks Later • Wound decreased in size • Drainage minimal • No signs of infection

35. 8 Weeks Later • Last application of bioengineered skin substitute

36. Thin epithelial layer over wound for first time in 3 years! Post Completion of Skin Substitute Application Regime

37. Therapeutic Impact • Wound Healed • No amputation • Days to heal 64 • Patient satisfaction “excellent” • Cost to treat = $12,308 • Amputation cost = $0

38. Case Study 3 72 year old female with a 1 year history of ulcer from PVD

39. Challenges • High risk for infection • Edema management

40. Progression Week 5 Week 3

41. Week 6 • Day 35 of treatment • Total number grafts 2 • Compression therapy applied weekly

42. Therapeutic Impact • Wound Healed • Days to heal 35 • Customer Services Scores = Excellent • Cost to treat = $3462 for grafts • Cost to amputate = $0.

43. No way to avoid ever having an audit Be prepared at all times Processes to ensure documentation is correct Diligence in keeping up with LCD information and be ready to convert to ICD-10 codes Audits

44. In Summary In an era of pay for performance and dwindling reimbursement, the challenge to provide quality, cost effective advanced wound care is higher than ever before. It is our responsibility to find ways to ensure that we are providing quality care that is cost effective to the patient and to the facility.

45. St. Anthony’s Wound Treatment Center/Senior Services Team

46. Thank You Questions?

47. References Available upon request