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Developing an Outpatient Wound Care Clinic in an Acute Rehabilitation Setting (CE)
People with disability are at high risk for skin breakdown, which requires ongoing prevention and management. An outpatient rehabilitation wound clinic was developed to handle a variety of acute and chronic wounds for this unique population. This article describes how two advanced practice nurses proposed the idea for the wound care clinic and formulated a business plan, which was critical to successfully administering an outpatient wound care service. Essential components of the business plan included the goals, scope of service, professional practice model, benefits, rationale, marketing analysis, predicted volumes, regulatory imperatives, and financial needs.
Two advanced practice nurses (APNs) with extensive rehabilitation experience had a vision to develop a not-for-profit, hospital-based outpatient wound care clinic (OPWCC) that offered comprehensive, holistic, coordinated, state-of-the-art wound care for people with disability and chronic illness. The APNs’ unique skill sets equipped them to perform histories and physical exams, coordinate and interpret appropriate diagnostic work-ups, offer nutritional guidance, implement cost-effective wound care modalities, provide patient education, assist with resources for wound supplies, and manage strategic follow-up. A combined 40 years of experience in rehabilitation, diverse advanced practice roles, and a collaborative blend of expertise were the essential ingredients for managing wound care patients in a specialized outpatient clinic. This article chronicles the APNs’ journey, which included a business-planning phase, essential start-up actions, and strategies to improve patient flow into a successful expanded wound care clinic.
A certified wound, ostomy, and continence nurse (CWOCN) had made a positive impact on every inpatient clinical unit in a freestanding 165-bed rehabilitation facility. Certified as a CWOCN in 2002, she quickly established her role as a nurse consultant. In this facility, staff nurses, medical residents, and attending physicians have daily requests for evaluations and recommendations for newly admitted patients with wounds and ostomies. This APN offered her expert opinion on wound prevention and treatment and educated many clinicians along the way. She created evidenced-based wound care protocols that provided structure and consistency for skin and wound management. This CWOCN implemented weekly wound care rounds as an organized strategy for follow-up that coincides with Joint Commission standards and recommendations. Medical staff and hospital leadership noted the successful wound care management and trends spearheaded by this CWOCN.
A family nurse practitioner (FNP) had experience in both inpatient and outpatient settings, with greater focus on a variety of specialty outpatient clinics serving general pediatric and adult rehabilitation populations. She established adult primary care and intrathecal baclofen pump clinics and served as a resource to an outpatient program addressing multiple disability types and issues. This FNP frequently was challenged to manage pressure ulcers when working with this unique population. Because of the complexities of wound care management and the many needs of disabled and chronically ill patients, these visits often were labor intensive.
Patients diagnosed with spinal cord injury (SCI), brain injury, stroke, spina bifida, and cerebral palsy are commonly seen in outpatient settings. These patients are neurologically compromised and are at an increased risk for pressure ulcers and other wounds. Pressure ulcers and skin and other wound-type issues are the result of immobility, decreased sensation, prolonged pressure, shearing forces and friction, moisture and maceration, and incontinence. Other pathophysiological factors underlying wounds include fever, edema, anemia, infection, ischemia, hypoxemia, hypotension, malnutrition, decreased lean body mass, and increased metabolic demands (Salcido & Popescu, 2009). Patients seen in outpatient rehabilitation settings have significant physical disabilities, multiple medical comorbidities, and extensive needs requiring increased time for management. Together, the two APNs hypothesized that outpatients with wounds would fare better in an organized collaborative interdisciplinary venue in which advanced wound modalities and coordinated follow-up would occur.
The formal proposition to develop a wound care clinic (WCC) was outlined in a fellowship application proposal. The fellowship, funded through an endowment by the Prince Charitable Trust, facilitated program development in the nursing field. An interdisciplinary committee of experienced clinicians and senior reviewers rated the proposal based on its probability of having a significant impact on quality of care at the hospital. The plan had to be clear, realistic, and consistent with hospital and nursing objectives. The plan’s goals were to use evidence-based practices in wound care management, demonstrate effectiveness and efficiency of the interdisciplinary outpatient venue, address patient concerns and medical needs to manage wounds and prevent recurrence, and develop educational materials pertinent to wound care management. The granted fellowship allowed for the time, flexibility, and resources to develop and implement a comprehensive OPWCC. The fellowship provided funding for a 0.2 full-time–equivalent salary and benefits for both APNs to develop the conceptual model. Expenses were paid for attendance at a national conference on skin and wound care, a site visit to another WCC, and equipment and supplies (e.g., a digital camera, color printer, photo paper, and additional ancillary costs detailed in the proposal budget).
The fellowship committee assigned a mentor to guide the endeavor. A vice president of patient care services/chief nurse executive, who had extensive business knowledge and skills, facilitated the process and helped with strategic planning and the timeline. An initial step was to determine whether other clinicians agreed a WCC could be beneficial. Physiatrists were queried to ascertain whether such a clinic would be used internally. A survey was conducted of rehabilitation attending physicians to determine if they preferred to manage wounds on their own or refer to a wound clinic. The results were favorable, with a 70% response rate. Thirty-five attending physicians completed the survey, and 89% were interested in sending their patients to the specialty clinic. As predicted, because it is labor intensive to care for rehabilitation patients with wounds, physiatrists preferred patient referral to a WCC, which could allow for increased patient flow through their respective clinics.
An important phase was to develop a written business plan, which is a required blueprint or summary describing the services considered. In today’s complex healthcare business environment, organizations need to strategically determine financial viability of any new endeavor. Consequently, the business plan needed to address products and services and provide information about the market, market strategies, competition, and operation and financial information (Bachrodt & Smyth, 2004). The advisor provided a proforma template with the following headings: goals, scope of services, rationale, professional practice model, benefits/risks, market analysis, volume projections, referral development, capital requirements (facility and equipment needs), regulatory imperatives, critical success factors, proposed budget, and recommendations. It took months to research the necessary information to complete each section.
During the business-planning phase, clinic goals were developed with a focus on patient care benefits targeted to specific populations (e.g., SCI, spina bifida, stroke, and brain injury). The scope of services was expanded. Practice issues that took into consideration each of the APNs’ distinct functions and abilities and the physician’s supervisory role also were identified. In the state of Illinois, the nurse practitioner (NP) role is somewhat restrictive. Illinois was the last state to allow NPs prescriptive authority. During the clinic preparation phase, NPs needed a collaborative agreement with physicians when delivering healthcare services. Currently, hospital bylaws in Illinois mandate that an attending physician of record be present for all patients at their first visit. Subsequent visits may be conducted by an NP as long as the physician is available through telecommunication. The physician should be consulted for medical problems, complications, emergencies, and referrals.
Next, market competition was assessed; this entailed determining how many other WCCs were located within the metropolitan area (few) and if any of them promoted services for people with disabilities (none). When determining outpatient rehabilitation trends, the population at highest risk was identified as SCI patients. Outpatient nurses were asked to provide an estimate of how many quadriplegic and paraplegic patients had pressure ulcers and had been seen at the facility during the past 3 months. This volume was considered a low estimate of the patients who potentially could be referred to the clinic. A projected treatment course multiplied by the estimated number of patients helped predict clinic volume. For example, patients with SCI who have nonhealing pressure ulcers typically are seen monthly for 6 months; when multiplied by 50 patients, this is equivalent to 300 visits.
The physician practice manager helped to formulate a proposed budget that emphasized marketing and critical success factors. There were no newly created positions, which limited additional salary costs. Planned equipment purchases were included in the proposed budget. The financial risks were considered minimal because wound care was already in practice in the rehabilitation environment. Marketing strategies were formulated to include networking with other healthcare providers via formal presentations, one of which was given at a national conference, and informal communication. The wound care nurse consultant communicated to her colleagues the availability of wound care services per the regional Wound, Ostomy, and Continence Nurses Society directory serving Northern Illinois. A brochure describing the wound care services was distributed as a public relations tool. Critical success also was contingent upon outpatient nursing support. Outpatient staff committed their support with the condition that the wound clinic would be scheduled on a day with a lower total clinic volume.
Although its creation was an arduous task, the business plan helped to cultivate ideas and purposes and target needs. Several things were learned as this plan was created.
The outlined business plan for an OPWCC in a rehabilitation setting included
1. Clinic goals
2. Scope of services
3. Professional practice model
6. Market analysis/volume projections
7. Referral development
8. Capital requirements
9. Regulatory imperatives
10. Critical success factors
11. Proposed budget/projected expenses
Pilot Phase and Tools
Before the implementation of the pilot clinic, the APNs met with the outpatient clinic manager to discuss schedules, determine staffing needs, and secure clinic space to maximize efficient patient flow. A physician with an interest in wound care was recruited to join the endeavor. During the pilot phase, the FNP and the CWOCN only treated preestablished patients. Initially, the physician was consulted only as needed to address significantly deteriorated wounds or for sharp debridement. After the OPWCC was permanently established, new referral patients were recruited and the initial evaluation was performed by the physician. The FNP conducted most re-evaluations, and the CWOCN continued to offer her expertise to all wound care patients.
A patient questionnaire tool was created to collect patient data, facilitate wound treatment, improve patient care, and ease patient flow. Patients were handed the 10-minute questionnaire at the time of registration, and the form was completed while in the waiting room. The tool focused on patient diagnosis, comorbidities, wound history, duration, and cause of the wound. Questions were asked about associated factors regarding patients’ healing ability and limiting factors affecting nonhealing wounds in addition to previously attempted remedies and treatments. The valuable information described in patients’ own words provides insight into their knowledge base and understanding of their own health condition (Figure 1).
The NP then developed another tool to help focus on the comprehensive wound evaluation—an evaluation form that captures the most pertinent health information as it relates to a wound. The form outlines questions that should be raised during patient interviews. The review of systems is not all inclusive, but the typical issues that can influence healing are listed. The exam portion highlights information necessary to complete a comprehensive wound evaluation. This template history and physical form has proved useful for training resident physicians in the OPWCC (Figure 2).
The pilot phase occurred during the last 3 months of the fellowship. Only 12 patients were referred due to very short implementation notification of the pilot wound clinic. The breakdown of diagnostic groups included 1 patient with rheumatoid arthritis, 1 with multiple sclerosis, 1 with cerebral palsy, 2 with anoxic brain injury, and 7 with SCI (2 patients had quadriplegia and 5 had paraplegia). Eleven patients had pressure ulcers, many with several skin areas, for a total of 37 wounds. One patient had an atypical LE wound. These patients were seen several times for a total of 21 outpatient visits.
After the pilot program was implemented, feedback was requested from a random sample of 25% of patients seen in the OPWCC. The patients were asked to answer four questions: (1) How satisfied were you with your overall wound care treatment today? (2) Did your wound care clinicians appear knowledgeable regarding your wound care management? (3) How well prepared do you feel regarding your wound care follow-up at home? (4) Did the care received at the clinic appear efficient and timely? Patients used a Likert-type scale of 1–4, with 1 = poor, 2 = fair, 3 = good, 4 = excellent. The results revealed outstanding patient satisfaction. According to the surveys, 100% of the patients rated the services as good or excellent, with the majority of ratings as excellent. The immediate feedback and initial positive experiences confirmed that the clinic was valuable.
Marketing the Established Clinic
The development of the OPWCC was a first-time initiative for the hospital and, uniquely, was run by APNs. Because of the novelty of such an event, the APNs felt it prudent to put together a presentation to highlight the pilot-phase outcomes and promote an established outpatient wound care program, which was disseminated at a medical staff meeting during which the mission, goals, scope of service, initial pilot data, and outcomes were articulated. Despite limited data, the physicians were impressed with the ideals, encouraged by the initial patient feedback, and optimistic about potential clinic growth. Several physicians reiterated their opinions of the clinic’s value to customers or patients. The majority of clinicians voted in favor of permanently establishing the specialty clinic with the APNs’ continued involvement. Since then, stronger support has been received. To increase patient volume, a physiatrist—who was interested in wound care management—joined the practice full time, which allowed for outside referrals and first-time evaluations.
The hospital marketing department was excited about the new enterprise and sought involvement by helping to develop a brochure to showcase the clinic’s philosophy and services. The clinicians met with the marketers several times to determine and agree on content for the brochure. The advertising team stressed that consumer-driven marketing is believed to be better received when highlighting and showcasing a physician working within an interdisciplinary model. Marketing data have demonstrated that consumers (patients and families) choose services based on hospital reputation and physician skill and expertise. To this end, administration and marketing personnel advised that the advertising be physiatrist driven, which meant the APNs were not prominently featured. It was felt that this marketing strategy most likely would benefit the reputation of the organization and the OPWCC with higher referrals. The first targeted groups were affiliated hospitals, nearby primary care physicians, and endocrinologists. The brochures were sent in the mail with a cover letter introducing the physician’s expertise with the collaborative team.
Personnel responsibility within the outpatient setting provided challenges. Several training sessions were directed at improving patient flow; nurses and patient care technician staff were required to attend. Efficiency finally was achieved by establishing the following process: (1) patient transfer to the exam chair or onto the exam table would occur before the clinician’s initial contact with the patient, (2) wound dressings would be removed and there would be visual placement for wound-drainage analysis, (3) wound cleansing, (4) assessment of equipment readiness (e.g., disposable measuring guide, gauze, cotton-tipped applicator). Re-education, mentorship, and staff recognition have helped ensure continued participation. The fast-paced, large-volume clinic requires special team members who are energetic and hard working for success to occur.
The APNs also had to meet with the outpatient manager to re-examine space prioritization and clinical nursing support for the OPWCC. It is a constant challenge to secure staffing for a labor-intensive specialty and large patient volume. The clinic’s success is due to the staff’s ongoing support. Patient outcomes and improved status reflect overall happy clientele. A primary referral source has been word of mouth from colleagues sharing the same space. The success of the wound outpatient program is evidenced by increased referrals and further expansion of the clinic. There are now six clinics monthly, and hundreds of patients have been cared for in the past 5 years.
Top 10 Lessons Learned
Reflecting on the past, it has been an incredible journey. What started as a shared vision by two APNs who received hospital and administrative support has flourished into a wound care team that provides comprehensive, state-of-the-art care for patients with disability and chronic illness. The clinicians have summarized their top 10 lessons learned to assist future APNs.
We would like to thank Laura Leigh Ferrio for her guidance throughout this entire endeavor; Dr. Kathy Stevens for her support with this article; Dr. Rosemarie King for encouraging us to write and seek publication; Drs. Marciniak, Satcher, and Soriano for working with us in the specialty clinic; and our patients who continually challenge and teach us each and every day.
About the Authors
Diane Dudas Sheehan, ND CPN APN CRRN FNP-BC, is a certified nurse practitioner at Rehabilitation Institute of Chicago. Address correspondence to her at firstname.lastname@example.org.
Mary H. Zeigler, MS CRRN CWOCN APN, is a clinical nurse specialist at Rehabilitation Institute of Chicago.
Authors have no relevant financial relationships to disclose. This article does not discuss off-label use.
Bachrodt, A. K., & Smyth, J. P. (2004). Strategic business planning linking strategy with financial reality. Healthcare Financial Management, 58(11), 60–62, 64, 66.
Baranoski, S., & Ayello, E. A. (2003). Wound care essentials: Practice principles. Philadelphia: Lippincott Williams & Wilkins.
Pittman, J. (2007). Effect of aging on wound healing: Current concepts. Journal of Wound, Ostomy, and Continence Nursing, 34(4), 412–415.
Salcido, R., & Popescu, A. (2009). Pressure ulcers and wound care. The Medscape Journal of Medicine. Retrieved March 15, 2010, from http://emedicine.medscape.com/article/319284-overview.
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