Care from a distance: wound care in rural communities

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Care from a distance: wound care in rural communities
Care from a distance: wound care in rural communities
When wound care patients need intensive treatment, the usual response is to transport them to the nearest hospital or specialty clinic. But it's a solution those in metropolitan areas take for granted because in many parts of the country, a simple trip to the hospital is a major production or not possible at all.

Specialists working in the wound care field are well aware of the challenges rural facilities face. Vast distances, difficult topography, transportation limitations and budget constraints are just some of the major barriers.

Skilled nursing facilities facing such daunting obstacles due to their remote locations must find creative ways to maintain high standards of care, including advanced staff training, maximizing expertise from vendors and consultants, deploying communications technology and exploring innovative clinical strategies.
Technology can be an effective clinical tool, stresses Marianna Grachek, president and CEO of the American College of Health Care Administrators.

“Today, given the ascent of the Internet, new low-cost diagnostic technologies and patient-centered care delivery models, nursing homes are in a prime position to lower their own costs of wound treatment while dramatically improving patient outcomes,” she said. “In a business model borrowed from the pharmaceutical sector, a formulary for wound care will transform the wound care industry from a ‘treatment' model to a ‘healing' model. This transformation is already underway.

“As formulary wound-healing outcomes data begins to proliferate, savings from the elimination of high-cost centers of care, such as hospitals and wound clinics, will be redirected in the form of reimbursements to lower-cost centers of care, like the nursing home and home health agencies, as providers systematically document wound resolution through healing.”

To be sure, rural facilities need to dedicate themselves to all the options available in order to overcome the disadvantages of a remote location, said Susan Girolami, RN, clinical manager for Cincinnati, OH-based Therapy Support. Among those she recommends: Developing a local resource who can advise on wound management and product selection; establishing a “mentoring alliance” in the organization; subscribing to clinical journals with a wound care focus; using the phone to discuss wound care issues with experts; and seeking out Internet and telemedicine solutions.

“Staff education can be obtained for any professional despite location if the resources are invested and a mentoring alliance is established,” Girolami said. “There is a certified wound care program that is provided in major cities several times yearly. The course is a comprehensive one-week educational program that provides a solid basis for an RN to become a wound care resource. Mentoring is always advisable for new practitioners and can be conducted by telemedia. Otherwise, consultants are generally not available in remote areas due to travel costs.”

Community character is also an important consideration, notes Jan Eaton, wound care specialist at Lane Frost Health and Rehabilitation Center in Hugo, OK.

“Many rural areas are economically depressed and patients have no insurance to cover the cost of wound care,” she said. “Also, transportation to the ‘city' for wound care is very costly. Patients often depend on family members for transportation and due to the costs associated with it, patients avoid care rather than imposing on family members.”

Prohibitive costs and limited availability of wound dressings in many rural areas also are issues for patients, who might tend to prefer folk remedies, such as black salve, udder balm, kerosene, bleach and axle grease, Eaton said. Moreover, she said, country doctors typically don't specialize in wound care, and that “their wound care knowledge is based on what they were taught in medical school and not in advanced wound care dressings and treatment modalities.”

Culture matters

Religious and cultural traditions also play a role in wound care, adds Diane Heasley, RN, vice president of clinical services for Paterson, NJ-based DermaRite Industries.

“In the Amish communities of rural Pennsylvania, transport to hospitals—let alone advanced wound care—is few and far between,” she said. “When I worked at Allegheny General in Pittsburgh, an entire family trekked from New Castle, PA, to Pittsburgh by horse and buggy. It took an entire day. The family did not believe in many of the practices, such as transfusion, so those traditions must be respected.”

Close relations with wound care vendors is essential for quality programs at isolated facilities, says Julia Melendez, RN, national clinical director for Joerns Healthcare in Van Nuys, CA.

“The primary challenge for rural facilities is access to the appropriate products to care for residents—particularly the products they would typically rent, such as therapeutic support surfaces,” she said. “These facilities should partner with vendors who will work collaboratively with them to develop a program to meet their ‘on-demand' needs for wound care modalities, such as negative pressure wound therapy and therapeutic support surfaces.”

The farther away a facility is from a metropolitan area, the more important its partnership with vendors becomes, Melendez said.

Vendors should provide comprehensive support regardless of geography, believes Mark Richards, vice president of clinical education at Reno, NV-based Accelerated Care Plus.

“If a rural facility needs vendor support to help with wound healing, the vendor should be prepared to provide it,” he said.

Clinical versatility

Because resources can be scarce in rural areas, clinicians working in these facilities are often called upon to wear many hats. Yet the value of a dedicated wound management expert cannot be understated, Girolami said.

“The facility must have a knowledgeable practitioner to communicate clinical assessment and outcomes for effective utilization,” she said. “It depends on how the community utilizes the resource—if the designee only provides consulting in a single facility, that person will have several roles within that facility. If the resource provides wound consulting to other area providers, they may be hired by one source and contracted to other agencies.”

Melendez concedes that while having a wound care practitioner is valuable, it is a tall order for rural facilities to find one.

“Generally, facilities make the determination based on the cost-benefit analysis to determine whether having a specially trained clinician to manage the facility's wound prevalence makes sense for them,” she said.


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Connecting to telemedicine

The scope of the Internet and wireless communications allows even the most remote long-term care facilities to have the opportunity to use some sort of telemedicine for wound care. But how much does it actually help?

-Jan Eaton, wound care specialist at Lane Frost Health and Rehabilitation Center: “Telemedicine could be very useful in rural wound care, but photography is not viewed favorably in all healthcare settings. The technology and training required for wound care telemedicine may not be available in all areas and may be very costly for rural healthcare providers.”

-Susan Girolami, RN, clinical manager for Therapy Support: “The Internet is a tool for research and education and telemedicine should be used for consultation. The burden lies with the facility to educate a dedicated resource and establish a working telemedia solution. Assign a dedicated staff member as a wound care resource.”

-Diane Heasley, RN, vice president of clinical services for DermaRite Industries: “Make sure those HIPAA agreements are signed and that you thoroughly educate staff before diving into the pool. If they are not educated, the expert on the other side will be wasting valuable time for data which should be in line before the call is made. Critical pathways for wound care should be established no matter what the arena.”