Host: Susan Karol, MD;

IHS Chief Medical Officer

Welcome to the IHS Clinical Rounds June 14th, 2012

Presenter: John Farris, MD;

CMO, IHS Oklahoma Area

“Organizing a Wound Healing Program:

Replicating a Model That Works”

Objectives for Today’s Rounds

• Define the key factors for developing an organized approach to wound

healing within Indian health care.

• Differentiate between healing wounds and building an organized wound

healing program

• Implement processes and strategies for a comprehensive wound healing program.

Accreditation

• The Indian Health Service (IHS) Clinical Support Center isaccredited by the Accreditation Council for Continuing MedicalEducation to sponsor continuing medical education for physicians.The IHS Clinical Support Center designates this live educationalactivity for a maximum of 1 AMA PRA Category 1Credit(s)™. Physicians should claim only the credit commensuratewith the extent of their participation in the activity.

• The Indian Health Service Clinical Support Center is accredited as aprovider of continuing nursing education by the American NursesCredentialing Center’s Commission on Accreditation.

• This activity is designated 1.0 contact hours for nurses.

Accreditation applies solely to this educational activity and does

not imply approval or endorsement of any commercial product,

services or processes by the CSC, IHS, the federal

government, or the accrediting bodies.

Disclaimer

Guidelines for Receiving

Continuing Education Credit

• To receive a certificate of continuing education or certificate of

attendance, you must attend the educational event in its entirety and

successfully complete an on-line evaluation of the seminar within 15

days of the activity. At the end of the evaluation, click on the

appropriate line to obtain your certificate, fill in your name and print

the certificate.

• If you need assistance, please contact Dr. Chris Fore (chris.fore@

ihs.gov) or Mollie Ayala (mollie.ayala@ihs.gov).

Faculty Disclosure Statement

• As a provider accredited by ACCME, ANCC, and ACPE, the IHSClinical Support Center must ensure balance, independence,objectivity, and scientific rigor in its educational activities. Coursedirectors/coordinators, planning committee members, faculty, and allothers who are in a position to control the content of this educationalactivity are required to disclose all relevant financial relationshipswith any commercial interest related to the subject matter of theeducational activity. Safeguards against commercial bias havebeen put in place. Faculty will also disclose any off-label and/orinvestigational use of pharmaceuticals or instruments discussed intheir presentation. Disclosure of this information will be included incourse materials so those participating in the activity may formulatetheir own judgments regarding the presentations. The coursedirectors/coordinators, planning committee members, and faculty forthis activity have completed the disclosure process and haveindicated that they do not have any significant financial relationshipsor affiliations with any manufacturers or commercial products todisclose.

Topics for Future Rounds

July 12, 2012: “The Baby Friendly Hospital Initiative”

Suzan Murphy RD MPH; Phoenix Indian Medical Center

August 9, 2012: “Standards of Care and Clinical Practice

Recommendations: Type 2 Diabetes”

Ann Bullock, MD; Cherokee Hospital

Sept 13, 2012: “Improving Timing Stroke Care: Advances in Tele-Stroke

Consultation” Dr. Bart Demaerschalk; Mayo Clinic

Meet the Presenter

Dr. John Farris is the Chief Medical Officer for the Oklahoma City Area Indian

Health Service and a member of the Cherokee Nation of Oklahoma. He attended

undergraduate schools at the University of Oklahoma in Norman, OK and Baker

University in Baldwin City, Kansas, attaining a B.S. in Biology in 1981. He attended

medical school at the University of North Dakota, School of Medicine in the INMED

Program and completed his medical education at Michigan State University College

of Human Medicine, receiving his medical degree in 1985. He completed an Internal

Medicine Residency at the University of South Dakota, School of Medicine, in Sioux

Falls, South Dakota, and also served as the Chief Resident in Internal Medicine for 1

year.

After residency, Dr. Farris worked as a staff physician in the Internal Medicine

Department and then was appointed medical director of the Respiratory Therapy

Department at the VA Medical Center in Ft. Meade, South Dakota. In February,

1996, he joined the staff at W.W. Hastings Indian Hospital in Tahlequah, Oklahoma

as the Director of the Emergency Department and was selected as Clinical Director

in November 1996. In August of 2004, he assumed the Chief Medical Officer duties

for the Oklahoma City Area.

“Organizing a Wound

Healing Program:

Replicating a Model That

Works”

John Farris, MD, Chief Medical Officer

Indian Health Service – Oklahoma City Area

Indian Health Service Clinical Rounds

June 14, 2012

IHS Priorities

Dr. Yvette Roubideaux - Indian Health Service Director

1. To renew and strengthen our partnership with tribes

2. In the context of national health reform, to bring reform

to IHS

3. To improve the quality of and access to care

4. To make all our work accountable, transparent, fair and

inclusive

Objectives:

1. Describe the factors in developing an organized

approach to healing wounds for American Indians

2. Highlight the difference between having an organized

wound healing program and treating wounds

3. Understand the implementation of a comprehensive

program on patient outcomes and satisfaction, the

financial impact on the facility, and barriers they will

face with implementation

DIABETES In America

• 23.6 million people in

25.2

77.7

119.3

0

20

40

60

80

100

120

the U.S. have

diabetes

• ¼ don’t know it

• 15% will develop

Diabetic Foot Ulcers

(DFU)

• Death rates are

increasing

2011 National Diabetes Fact Sheet

14.2% of American Indians and Alaska Natives aged 20 yearsor older who received care from IHS have diagnoseddiabetes.

16.1% of the total adult population served by IHS hasdiagnosed diabetes, with rates varying by region from 5.5%among Alaska Native adults to 33.5% among American Indianadults in southern Arizona.

Among Native Americans in Oklahoma the rate of diabetes is15.2%

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

Wounds: a serious health risk predictor for

Native Americans…

1. Lee JS, Lu M, Lee VS,

Russell D, Bahr C, Lee

ET: Lower extremity

amputation. Incidence,

risk factors, and

mortality in the

Oklahoma Indian

Diabetes Study.

Diabetes. 1993:42:876-

82.b

Do diabetes-related wounds

and amputations cost more lives

than some cancers? YES! Nearly half of all

unhealed neuropathic

ulcers have other co-

morbid states that will

result in patient death

within 5 years if not

resolved

ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 4 No 4strong 2007;4(4):286-287.

Disparity Exists for Indian Health

Service Patients

• Wound patients have ahigher level of co-morbidconditions

• Education on risk factorsand Peripheral ArterialDisease is insufficient

• Amputations are viewed bymany providers as definitivecare for even simplewounds

• Consultation with specialistsis not readily available

• There is no mechanism forcontinuity of care

• Clinic structure is notdesigned to merge theneeds of patients withwounds that require extratime and specialinterventions

• There is a consistentpractice of utilizing CHSfunds for eitherconvenience referrals oremergent/urgent care

National Economic Costs Comparisons…

0

200

400

600

800

1000

Cancer PAD andDFU/Wounds

NationalDefense

HHS Overall

$227

$515

$671

$892

$ B

illio

n

Why did we develop a Direct Wound Care

Program

Increasing expenditures to care for patients with wounds

without consistent results

Increasing amputations

Oklahoma City Area cost for outsourced wounds averaged more

than $17,000 - $22,000 for even simple wounds;

CHEF cases that began as wounds often exceeding $1 million dollars

with devastating patient outcomes (2004 dollars)

Complications of Diabetic Foot Ulcers

DFUs that persist more than 4 weeks have a 5-fold greater risk of

infection.1

Development of an infection in a foot ulcer increases the risk for

hospitalization 55.7 times and the risk for amputation 155 times.1

“Infected neuropathic ulcerations are the leading cause of diabetes-related

partial foot amputations at the Phoenix Indian Medical Center.”2

Foot ulceration is a significant risk factor for lower-extremity amputation in

Native American Indians.3

19

1. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.2. Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr

Med Assoc. 1989;79:447-50.3. Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care.

1996;19:704-9.

Diabetes Neuropathy Infection Amputation Foot Ulcer

Costs of Letting Wounds Progress

6. Kruse I, Edelman S. Evaluation and Treatment of Diabetic Foot Ulcers. Clinical Diabetes. 2006;24 (2):91-93.

7. Stockl K, et al, Costs of Lower-Extremity Ulcers Among Patient with Diabetes. Diabetes Care 27:2129-2134, 2004.

8. Reiber, GE, Boyko EJ, Smith DG. Lower Extremity Foot Ulcers and Amputations in Diabetes. In Diabetes in America, 2nd edition. Bethesda, MD; National Diabetes

Data Group, National Institutes of Health, NIDDK NIH Publication No. 95-1468, 1995.

<$200 to $3,600 $5,000 - $12,000 $19,000 to >$103,000

Wounds Have a “Golden Hour”

From the onset of the wound…patients need

definitive wound care sooner than later

30 days to prevent further breakdown,

infection, progression to amputation

Case Examples:

With Organized Direct Care Wound Program 42 y/o male with scrotal abscess

I&D including brief IHS hospital post-op stay w/referral to

wound care

Remained outpatient w/return to work in 5 weeks

Cost of care: @ $2,000

Without Organized Wound Care 44 y/o male with scrotal abscess I&D including brief hospital

post-op stay w/o referral to wound care Became septic w/exacerbation of other co-morbid conditions

hospital readmission and transfer to private sector ICU

Cost of care: >$1 million

Aggressive treatment leads to fast healing…

20 y o male with full thickness burns to left foot from heat exposure in bon fire

incident; ED visit Saturday night. Patient presented two days after insult with

loose rupture blisters and open wounds to lateral aspect of foot 6 inches long;

blisters to base of great toe; and plantar surface injury. The loose tissue was

debrided, dressed per wound protocols, given antibiotics/pain RX, supplies for

dressings and with RTC in one week. Four weeks later patient was healed of all

wounds – cost of care: <$150.00

Quality of the

person’s experience

Dollars spent

For the full cycle of care

Quality includes clinical outcomes and

the persons experience

>99% Patient Satisfaction Rates

Patients Do Notice:

“I have almost given up hope for my sister’s ulcerated sore on her right foot, since she

has been in a wheel chair for 7 years. Her daily activities have been very limited because

of her foot. She’s been in and out of the hospital for it. Twice she’s been told amputation

maybe a last resort, but twice we have pleaded with the doctors for alternative.

I am truly grateful for the good doctors, and nurses, and staff who does all this hard work.

I know because since my sister started in this program in February and up to now, this is

the miracles I have been witnessing that it works. The deep wide hole that was once

there is now a scar, a reminder of how lucky my sister is to still have her foot”!

“I cannot tell you what the program has done for me. Both my leg and my head. I was

trying to live with my leg the way it was and never dreamed there was any more than

could be done. I am so ecstatic with the improvement that have already given me that I

have gone out, bought a bike and am riding around our wonderful National Parks trying to

lose this extra weight that I have. To say, “thank you” doe not even begin to tell you how

positive and encouraged I am and also my family.

Yes the IVIVI has take the swelling way down. My ankles are almost the same size. I also

think that the pocket of infection is draining less. I am using my leg more and the swelling

is almost non-existent. I will be good about using it for the rest of my season here,

although my driver accuses my of shorting out my wireless mike.

I am so happy with what we have done so far, I can’t wait to try this other thing.”

“Good Morning, I just wanted you to know that the Indian Health Service Wound Care

team has saved my mother’s feet again and immediately addressed the wound issues

that have plagued my mom since August. I cannot tell you how much I appreciate this

program and the Clinic staff. Everyone was courteous, knew the goals, knew how to

help each other and my mom was impressed with their care to her just not trying to

herd her in so that they can get her out. I am truly thankful to everyone. Just a huge big

thanks”.

Case Examples:

patient satisfaction counts

Received patient after 7 months of open

wound with dry dressing; current

treatment – recommended by outside

podiatrist – dry dressings with monthly

follow-up visits; amputation anticipated

with further deterioration of the wound.

Treatment has been complex but the

patient is highly satisfied with the care

and will not require surgical intervention

to heal the wound.

Cost to treat the osteomyelitis: <$1000

for the Tornier calcium sulfate mixture

and topical antibiotics/antifungal.

Exposed bone

Nephrologist

Typical Care Structure: Wounds

Approach to Healing Wounds:

Incidental vs. Organized

• Patients seen in general clinic

• Wounds referred based on provider

comfort level and treated based on

personal preference

• No wound care specific formularies,

documentation, policies or

procedures

• Patients seen in blocked “wound

clinic”

• Staff trained in wound care treating

patients with wounds

• Specific formularies for supplies and

medications, ability to document and

bill for wound related services,

policies and procedures for patients

with wounds

Use an organized approach to

change

Plan

Do

Check

Act

Re-evaluate

Diagnostic Radiology

Nutrition

Vascular Surgery

Behavior Health PHN/CHR

Plastic Surgery Dermatology Pedorthist/

Diabetic Shoes

InfectiousDisease

Naturopathic Traditional Medicine

Endocrine Nephrology

Wound Clinic: Hub of Care Coordination

Wound Healing Model

Define the Scope of Care

• Meet or exceed the Standard of Practice

• Use established proven clinical pathways, treating all wound types

• Re-organize and standardize supplies and medication formularies specifically for patients

with wounds at all sites offering wound clinic

• Offer advanced and adjunctive therapies

• Control CHS referrals: no “evaluate and treat” be specific

• Gather data to benchmark against other wound programs and identify areas for

improvement

• Improve and investigate all wound care reimbursement avenues

• Streamline access to wound clinic

Clinical Pathways save time,

money, and improve practice

– Cost increases with time – designed to heal for the least cost

with aggressive early intervention

– Addresses root cause of the problem to assist with clinical

decisions and pathway application

– Pathways that clinically produce a >90% heal rate

– Pathways include: x-rays, lab, sharp conservative debridement,

management of infection and edema, dressings and off-loading,

advanced treatment modalities

Re-organize and standardize

supplies and medications

for patients with wounds

• Reduces waste and duplication

• Easier to learn and apply

• Helps to contain and predict costs

• Communicates a message of clinical competency and

organization

• Encourages system wide availability of formulary items

• Promotes consistent patient care

Adjunctive/Advanced Treatment Modalities

PRP and Living Cell Therapy

Negative pressure wound therapy

Pulsed Electro Magnetic Field therapy (PEMF)

Ultrasound Debridement

Topical Oxygen therapy

Case Examples:

Advanced Therapy in clinic – no surgery

Initial Referral to Plastic Surgery – referred to

wound clinic to confirm need for referral –

Female in mid twenties with traumatic

Seroma from Auto vs. Pedestrian incident,

evaluated and treated as outpatient,

effectively healed using advanced therapy,

aggressive topical bio-burden management

while patient worked; no functional disability

or restrictions; no residual joint pain.

(confirmed on x-ray there was not joint

involvement of infection prior to starting OP

treatment. Patient has remained healed.

Cost of care <$3,000 vs. cost of Plastic

Surgery ? 3

Sinus tracks from

infection 7 – 9 cm in

length

CHS Referral Adjustment Healing Need

Identified

Not available in wound clinic

Referral

To

CHS

Be specific about the need – refrain from Evaluate and Treat

Referrals as a routine

Resume care for the wound as soon as possible; no outside

orders for wound care treatments, or supplies

dictates

Results obtained for the

record

Patient care adjusted or

care coordinated

Rethink –

‘evaluate

and treat’

referrals

Obstacles to Achieving Greater

Value in Wound Healing

– Policy and funding barriers

– Not understanding and mitigating patient limitations

– Lack of “buy in” by clinicians

– Clinician non-compliance with treatmentrecommendations

– Skipping steps in the pathways

– Identifying appropriate clinical approaches

– Lack of wound specific supplies/advanced therapy

– Wait and see medicine

– Premature discharges and inappropriate transfers

Bolster Competencies and Build

Consistency Bolster Competencies

through:

Clinical Experience/Mentoring

• Billing/Coding Assessment

• Documentation Awareness

• Training

Build Consistency

through:

Increasing knowledge

Understanding biases

Case review/reflection

Pathway Compliance

Change is not always easy…

• Recognize there is a opportunity; build in reform

• Make the most of the work of others

• Re-design processes to improve the quality of and access

to care

• Meet the needs of our patients

• Identify and diminish system weaknesses

• Develop an internal culture of change

• Support the transition for the team

HOW SHOULD AN ORGANIZED

PROGRAM LOOK?

Organized Program

Meets or exceeds

Standards of Practice

Independent

Documents outcomes

Committed

and

accountable

Standardized

Multi-disciplinary

Wound Care Should:

If you don’t test; you guessed…

Most perceptions of wound care is that “we are already doing a

good job”

• Tracking simple data elements can give you a lot of information

• First year experience

– 3171 total patient visits – 265 visits per month

– 113 active patients

– 446 new patients

– 333 healed patients

– Cost per healed patient $3603; with advanced therapy @$4250

– CHS savings of $6 million

Wound Program Results

• Amputations decreased to less than 2% for patients in theprogram with an overall decrease for the Area of 36%

• Less than 3% recidivism rate

• Almost zero ‘no show’ rate

Be open to suggestions

• Not ‘cook book’ medicine

• Designed to support standardization and best practice; may

include ‘field tested’ treatments

• Designed to ‘assist’ clinical decisions

• Promotes revision of care guidelines and best practice

• Requires a commitment to ongoing education

• Identifies key elements of collective importance

• Used to benchmark care

Driven by the need of the patients

• Consider the patient

Consider the culture

Consider the impact

• Looks at current process

A program should:

• Foster community participation, and

• Make it easy for patients to participate

Essentials for a Wound Healing Program

1. In the simplest form, wound clinic essentials

include:

a) supporting policies/procedures and training

b) wound care provider (physician or mid-level)

c) support staff: nurse to assist provider

d) supplies and medications to support multi-modal treatment options

(Pharmacy and Supply Formularies)

e) clinic space to conduct clinic including: podiatric/wound care chair, and

locking storage, instruments/equipment

Time is More than Money –

Build on a proven platform

• Simple adjustments in practice, flow, and care can

produce great benefit:

– Adopt a best practice model

– Reduce amputations

– Enrich the use of CHS funds

– Assure Improved Patient Care

Just because you’ve done it that

way…

In the end…

It’s all about the patients.

Next Steps…

1. Would an organized approach save your patients amputations?

2. Would an organized approach add value and save limited

healthcare dollars for your facility?

3. What barriers do you anticipate if you choose to modify your

current program?

Contact:

Dr. John Farris, Chief Medical Officer

Oklahoma City Area

405-951-3776