Collaboration in Care of Wounds

By: Edward Ratner, MD

Physicians actively involved in home care recognize the importance of collaboration. Physicians typically and appropriately depend upon nurses to plan and implement care of wounds, especially in the home setting.

While this type of collaboration recognizes the special skills and knowledge among nurses, it should not promote disinterest by physicians in wound care. Physicians have basic sciences training that permits appreciation of the mechanisms of wound development and healing. We also have the ability to understand the wound in the context of the patient's other illnesses and treatments.

The physician is ultimately responsible for a wound, even in home care. The cause and effect of this responsibility varies. In some case, the wound is created by a surgeon's direct act. In others, the physician's management of problems such as nutrition, pedal edema or peripheral vascular disease contribute to wound development or affect healing. We order the wound treatments through our certification of the care plan (i.e. signing of the 485). We must certify the medical necessity of durable medical equipment such as pressure reduction mattresses.

The American Academy of Home Care Physicians hopes physicians will increase their active involvement in all aspects of wound care in the home. We hope physicians will be actively involved in careful observation and documentation of the status of a wound, patient and family teaching, and treatment decision making. Only then will wound care be a true collaboration of the home care nurse and physician.

Another type of collaboration occurs in care of some wounds in the home. When intravenous antibiotics are required or when a wound is present in a patient receiving parenteral or enteral nutrition, collaboration is necessary between the home care nurse, the home infusion pharmacist and the physician.

To learn more about such collaboration, I recently attended the 11th Annual Meeting of the National Home Infusion Association. I learned that home infusion has become increasingly complex as it has grown in scope and importance. Infections caused by organisms resistant to oral antibiotics (e.g., methcillin resistant Staph. Aureus) have become more common. New parenteral medications can be given at home for a wide variety of inflammatory and immune diseases, such as rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease and immune deficiencies. At the same time, advances are occurring in our understanding of management of long-term venous catheters. Enteral nutrition programs, also a part of home infusion therapy, offer a choice of over 120 feeding solutions and a variety of sophisticated and portable pumps for continuous feeding. I came away from the meeting with an even greater respect for the knowledge and skills of our partners from infusion nursing and home care pharmacy.

The importance of home infusion therapy will likely grow further. As we debate details of a Medicare prescription drug benefit, it is an ideal time for changes in Medicare policy regarding payment for parenteral drugs at home. Unlike other prescription drug coverage, paying for home infusion could actually save Medicare money. This could happen with a reduction in post-hospital nursing home stays for daily injection of a parenteral medication, such as vancomycin. The cost of home treatment would be less for Medicare in such cases. For patients currently receiving Medicare coverage for parenteral medications administered in physician offices, the costs to Medicare for home based treatment would be comparable to the present system. Thus, even with a constrained federal budget, a Medicare home infusion pharmacy benefit is sensible. Physicians and our partners in care of Medicare patients should make sure our political leaders are well informed on this issue.

The AAHCP has plans to build on our members' interest in wound care and in infusion therapy. New educational materials prepared by the Academy on these topics are in the early stages of development. Stay tuned.