Spotlight on Regulators and Payers
Patti Gable Burke
BSN, RN, CWOCN
President‘s Message:
Political Action, the WOCNCB and You
Anyone who is in our specialty is passionate about the care we provide. Now the care we provide is the focus of attention on a national level and in some cases on a state level.
After considering all the forces that are impacting and could impact our specialty in the future, the WOCNCB has developed a new strategic plan that will guide our initiatives for the next five years. One of our objectives is to communicate the value and purpose of WOCNCB certification to key stakeholders including regulatory agencies and payers. Board Certified Wound, Ostomy, Continence and Foot Care nurses need to be at the table with the regulatory agencies and payers to assist them to make correct decisions that will ensure our patients receive care that will produce the best outcomes.
The WOCNCB has been monitoring and communicating with regulatory agencies and payers whose goals include reducing the incidence of pressure ulcers. Below are some of the initiatives that the WOCNCB is following or involved in.
In collaboration with the WOCN Society, we developed a position statement for the Entry Level WOC Nurse. This document served as an introduction to the WOC specialty and the roles of the WOCN Society and the WOCNCB, as well as to the rigorous clinical and classroom educational requirements of the WOCNCB. The position statement and a Wound Care Certification Comparison Chart that presents the differences among available wound care certifications were sent to state healthcare and hospital associations, state boards of nursing, and other key contacts. As a follow up, the WOCNCB will send a WOC Education Program chart developed in collaboration with WOC Education Program Directors and the WOCN Society. This document will provide a quick reference for persons interested in attending an approved educational program.
An initiative that could greatly impact nursing is taking place in New York State. Senate Bill S1074 and House Bill A 2709 have been introduced to advance the profession of nursing. The bills propose that within 10 years of signing, a bachelor's degree would be required in order to practice as a Registered Nurse. Those RNs who are currently licensed or are currently in school before the bill is signed would not be affected by this change. If this becomes law, other states may follow New York's education requirements for becoming an RN. Many thanks to Heidi Cross, CWOCN, for volunteering to monitor this initiative for us.
The WOCNCB is monitoring several programs that the Centers for Medicare and Medicaid Services (CMS) are sponsoring. One program, set to run from July 2009 through June 2012, will take place in Arizona, Mississippi, New York and Wisconsin. CMS is asking long-term care facilities to join the Nursing Home Value-Based Purchasing Program. This pilot program will award points to nursing facilities that perform well on quality measures in four areas: nurse staffing, avoidable hospitalizations, resident outcomes, and the scope and severity of deficiency citations a home has received during inspections. Facilities with the highest points or with the greatest improvement will be eligible for a performance payment.
Another program held by CMS last year in all CMS regions has kicked off a national focus on reducing pressure ulcers. The 2008 Midwest Consortium Regional Meeting for Quality Improvement and Survey and Certification Operations was attended by representatives from the following states: AR, IL, IN, IA, KS, KY, MI, MN, MO, NE, ND, OH, OK, SD, and WI. Among the goals that were identified for this meeting were to:
- Decrease the incidence of pressure ulcers in nursing homes and hospitals.
- Plan inter-organizational efforts among various stakeholders, including the CMS Division of Quality Improvement, state health agencies, and Quality Improvement Organizations. The WOCNCB has sent a letter to the administrator who presided at the Consortium meeting, Ms. Teresa Titus-Howard, MSW, MHA, offering our participation in the dialogue for this important group. An interview with Ms. Titus-Howard is included in this newsletter.
Many other states, such as Wisconsin, Iowa, Indiana and New Jersey, have established committees or programs to help reduce the incidence of pressure ulcers. Several CWOCNs are currently involved in their state initiatives. An article in this issue by Dea Kent, CWOCN, describes how she became involved in the Indiana program. If you are involved in your state program to reduce pressure ulcers, please contact the WOCNCB to assist you in communicating the value of the Board Certification. For those of you who do not know if your state has a program in place to reduce the incidence of pressure ulcers place, I encourage you to contact your state's Quality Improvement Organization. Click here for a list by state.
As a Board Certified Wound, Ostomy, Continence or Foot Care Nurse, you have a wealth of knowledge and experience to share with those individuals in your state and the nation who make important decisions that affect how patient care is provided, who provides the care, and how care is paid for. All it takes is one concerned nurse and one phone call.
To quote the late anthropologist Margaret Mead, "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it's the only thing that ever has."
Patti Gable Burke, BSN, RN, CWOCN
President WOCNCB
Certification eNews EXCLUSIVE: An Interview with CMS
Marsha Berenson, Marketing Manager, WOCNCB
When marketing people want to learn how big a trend is, we do a Google search. Today I learned that over a quarter of a million articles containing the phrase "Pressure Ulcer" have been posted on the Web in the U.S. since August 5, 2008.
That's a big trend, but you already knew that from your daily work with patients. However, you might not know the significance of August 5, 2008. That's the date the Centers for Medicare and Medicaid Services (CMS) announced the first contract awards to Quality Improvement Organizations' (QIOs) 9th Scope of Work (SOW). And the 9th Scope of Work is the contract focused on reducing rates of pressure ulcers in nursing homes and hospitals.
To learn more about CMS activities since the initiation of the 9th SOW last August, I recently interviewed Ms. Teresa Titus-Howard, Associate Regional Administrator, Kansas City Division of Quality Improvement. Ms. Titus-Howard gave me some background about CMS's role in the pressure ulcer initiatives occurring in all 50 states, Puerto Rico, U.S. Virgin Islands, and Washington, D.C.
Ms. Titus-Howard explains that soon after the contracts for the 9th SOW were granted, CMS's Consortium for Quality Improvement and Certification Operations (CQISCO) collaborated to bring together stakeholders in every CQISCO region nation wide to see how they could improve pressure ulcer care for CMS beneficiaries. Her office conducted the Midwest Consortium Regional Meeting on September 3-4, 2008, in Kansas City, MO.
Over 100 stakeholders from 26 states attended. Attendees included representatives from hospital, nursing home, and home health care agencies, CMS, state survey agencies, and QIOs. The QIOs are organizations that CMS contracts with to serve in each state or U.S. territory to review medical care received by beneficiaries and help them resolve quality of care complaints. The QIOs also work with different health care providers to improve specific patient care issues, such as the reduction of pressure ulcers. (Click here for a directory of QIOs.)
The goals and objectives of the Midwest Regional Meeting included informing stakeholders of CMS's efforts to increase quality care, planning inter-organizational efforts to reduce incidence of pressure ulcers, and to identify best practices that improve care in the area of pressure ulcers. In addition, state-specific sessions were held where participants identified current and prospective state-specific approaches to pressure ulcer prevention and care.
Ms. Titus-Howard is very enthusiastic about last year's meetings about the role CMS is playing: "When I look at our Consortium and the task we are asked to accomplish with respect to stakeholders, it excites me," she says. "CMS has taken a proactive role as facilitators and conveners to bring stakeholders together and to support them with our expertise and data."
Although the final reports for the pressure ulcer and initiatives outlined in the 9th SOW will not be evaluated until the 18th month of the SOW, in January, 2010, Ms. Titus-Howard has already seen stakeholders from her meeting and from other regions leading change. "Some states use civil monetary penalties imposed on nursing homes and hospitals by the Survey and Certification Division for violations of the conditions for participation in CMS' programs to fund pressure ulcer reduction efforts," she explains. "Other states are actively pursuing other collaborative and/or funding opportunities to improve the quality of pressure ulcer care for patients."
For most of you, the national focus on care and prevention of pressure ulcers is an example of "preaching to the converted." But you will no doubt agree that the emphasis that CMS has put on this issue will be beneficial. Ultimately, the increased attention to this medical issue has placed a spotlight on the need for quality, evidence-based health care — the level of care those of you who are Board Certified wound nurses already provide.
"Show Me State" a Showcase for Reducing Pressure Ulcers
Marsha Berenson, Marketing Manager, WOCNCB
Missouri, known as the "show me state," has been focused on pressure ulcer prevention since the 1990s. Learn how the state's QIPMO program, an evidence-based program focused on care by expert nurses, works to improve long-term care, including incidence of pressure ulcers, throughout the state.
State departments of health and social services looking for ways to control the cost of long-term care would do well to focus their attention on Missouri. Nursing homes in the state have already saved over $4.7 million in care costs in 2007-2008 alone by preventing common problems such as urinary tract infections (UTI), bowel and bladder incontinence, and complications from daily restraints. The state is also seeing similar success in prevention of pressure ulcers; the results will be released this summer in an upcoming issue of Geriatric Nursing.
What sets Missouri apart and holds it up as a model even for the Centers for Medicare and Medicaid Services (CMS)? It is the Quality Improvement Program for Missouri, or QIPMO, a joint program of the Missouri Department of Health and Senior Services and the University of Missouri Sinclair School of Nursing. The program is separate from, but cooperates closely with, the Quality Improvement Organization (QIO) managing the CMS program in the state.
According to Dr. Marilyn Rantz, PhD, RN, FAAN, and Professor at the Sinclair School of Nursing, the QIPMO program was founded in 1999 after a literature review and a state research project on how to help facilities improve the quality of care showed that expert advanced practice nurses in nursing homes helped improve patient outcomes. The result was a clinically-focused, consultant model to support nursing homes.
"This program is focused on helping nursing staff get the latest best-practice information and help in making adjustments in care delivery in nursing homes to improve quality of care," Dr. Rantz says emphatically. "Having nurses with graduate-level nursing education is a factor — the critical piece."
The Missouri model involves well-prepared, graduate-level, gerontological-expert nurses who serve as consultants. Their role is to help nursing homes implement best practices in all aspects of care including pressure ulcers, weight loss, falls, bedfast residents, incontinence, UTI, physical restraints, and depression. Today, the QIPMO program employs five part-time registered nurses with expertise in gerontological nursing; most of them are advanced practice nurses. Funding comes from a per-bed charge to nursing homes.
The QIPMO program takes a team approach. Each nurse consultant works directly with the nursing staff and others in the nursing home like dietary, restorative, and activity staff, to form a team. Special attention is given to assess high-risk patients and to help staff carry out effective care plans. "The nurses must have complex critical thinking skills and the education, clinical and interpersonal skills to interview and work with patients and staff," explains Dr. Rantz. "They meet staff where they are - it's not a 'cookie cutter' program."
Carol Siem, MSN, RN, BC, GNP, and Clinical Educator at the Sinclair School of Nursing, has been a QIPMO nurse consultant since 2001. Recently, she has noticed a change in nursing home residents. "Typically, we see the trend for long term care residents getting older, which does not mean better health. They are frailer, with more co-morbidities and more illnesses in long-term care." To address this trend, the state is emphasizing prevention. Ms. Siem explains, "If we can prevent UTIs or pressure ulcers in long term care — we work hard with the CNAs, LPNs and RNs to manage prevention in the long run — it is better for everyone."
With respect to wound and continence care, if a long-term care facility is unable to manage a wound or continence issue, they may call in an advanced practice nurse wound consultant.
Ms. Siem reports that few Board Certified Wound, Ostomy or Continence Nurses are employed at Missouri nursing homes, although they are generally seen in hospitals. "The nursing shortage has impacted long-term care. There are not enough RNs to go around, let alone Board Certified nurses," she says.
Ms. Siem is enthusiastic about Board Certification. "I'm a Board Certified Gerontological Nurse Practitioner," she explains. "I am in nursing practice. Nurses recognize the value but practicing nurses are not always sure if administrators are really aware of the importance of Board Certification. In the long run, it pays for itself — in prevention. In the reduction of time to heal. Health care administrators are frequently focused on short term — from initial outlay of cash, but not on long term benefits. I say spend the money up front and you'll save in the long run."
Saving money, while at the same time saving lives and improving quality of life, are issues at the forefront of the healthcare industry today. Could duplicating the QIPMO model be a solution? And how would widespread use of the model affect wound, ostomy and continence nurses? Ideally, a focus on evidence-based practice and graduate-level nursing would increase the prestige of the nursing profession and put the spotlight on nurses who continue to develop their knowledge and skills. However, only time will tell.
For more information about QIPMO, or for Missouri certificants who wish to contact the QIPMO nurse in their area, visit www.nursinghomehelp.org
Active Collaboration: How Indiana WOCs Help to Effect Change
By Dea Kent, MSN, NP-C, CWOCN
State departments of health are taking action to reduce the incidence of pressure ulcers. Here is how one Board Certified nurse got herself invited to "sit at the table" with Indiana decision-makers.
We will prevent pressure ulcers. We will know the facts. We will take action.
Those are statements that are commonly spoken by wound ostomy and continence (WOC) nurses all over the United States, and by many around the globe. But, in Indiana, these statements are being spoken by nurse aides, staff nurses, managers and administrators, patients and family members in all facets of the healthcare continuum. Why?
In 2006 and 2007, development of pressure ulcers after admission to the hospital was the most reported event in Indiana's Medical Error Reporting System. This was not acceptable in Indiana, and so the Indiana State Department of Health (ISDH) decided to do something about the problem. The ISDH began investigating what other states were doing about pressure ulcers. Certainly, they saw the work being done in New Jersey, at that time, and felt that the solution to reducing pressure ulcers didn't lie with just one person, or one program, but would be and should be a collaborative effort.
This thought was a catalyst for developing partnerships with key organizations. ISDH first partnered with the University of Indianapolis Center for Aging and Community (CAC). In October 2007 the ISDH kicked off the Indiana Pressure Ulcer Quality Improvement Initiative with a Leadership Conference focusing on pressure ulcers. The attendance at this conference proved that there was much interest in the problem of pressure ulcer development, as well as a focus on prevention. The ISDH/CAC partnership responded to the need by choosing to develop a pressure ulcer prevention initiative — a collaborative based on the Institute for Healthcare Improvement's Breakthrough Series model. This model is based on the notion that there is a gap between what we know and what we do.
This is not news to wound providers — we have proclaimed that for a very long time! However, what the collaborative in Indiana is doing supersedes the traditional thought of where that gap lies and who is in the gap! In Indiana, the statewide initiative embraces home care agencies, extended care facilities, acute care hospitals, family members of patients, and the patients themselves! Indiana has worked to provide education about pressure ulcer development and prevention to all those who should be involved, including every level and type of staff member at the agency — the housekeeper, the pharmacist, the maintenance worker, and not just the nurse!
This complex collaborative has been a true collaboration among many organizations in the state, and includes everyone from the marketing company to the patient advocacy organizations. And, it involves WOCNCB–WOC nurses as well! Our collaborative is comprised of 100 facilities across the state — a rainbow of home care, nursing homes, and hospitals.
I got involved in the initiative after much of the groundwork was decided. The method being used to give information to all the people and agencies involved includes webinars, live seminars and promotion of relationship building in the immediate community and region. I can take no credit for the pre-planning and vision of the collaborative. However, what I can take credit for is making a phone call. I called the ISDH because I could not identify an Indiana WOC nurse as a formal part of the collaborative effort. There was a professional consultant who is a WOC nurse advising this collaborative, and I was glad for that input. However, as an Indiana WOC nurse, I wanted to make sure that the Indiana Board Certified WOC nurses were represented.
I serve as the President of the MidEast Region of the WOCN Society, so I felt an obligation to be an advocate for the WOC nurses around the state. A member of the MER Board, Joy Pittman, also from Indiana, serves the region in the capacity of a trustee. I felt that as a leader of the region, Joy should be involved, too. So, I volunteered her! After interviewing with the administrator for the collaborative from CAC, Joy and I were invited to be "clinical content expert members" of the collaborative.
"I think many of us have great ideas for our facility, our organization, our state, that relate to fixing the clinical and operational challenges we face as WOC specialists."
My perspective of our job with the collaborative is that we take all the great ideas from "around the table" and we put the clinical spin on them. We have spoken at the live seminars on topics such as care coordination and building a collegial culture. We attend the webinars to offer our information and support to those who have questions. We have been a part of developing hand-off communication tools, as well as a data collection tool to monitor the data about facility–acquired pressure ulcer development in the participating facilities in Indiana.
Am I doing something extraordinary? I don't think so. However, I think many of us have great ideas for our facility, our organization, our state, that relate to fixing the clinical and operational challenges we face as WOC specialists. In Indiana, I felt very glad that our health department had recognized an issue and wanted to do something formally to offer a solution to some of those challenges. And when I found that a WOC nurse from Indiana was not "at the table", I acted. I called the ISDH and explained that they needed a WOC expert from Indiana to give input on this program. In retrospect, it was probably a bold move, but it was a phone call that anyone could have made.
In Indiana, the collaborative is an 18-month project. But out of this project have come visible needs: the need for education about wounds and skin for nurses and nurse aides, the ability to recognize what is and isn't a pressure ulcer, the need to know what types of products and support surfaces are available and the need to understand when and what to use to prevent and treat skin and wound issues. This is a massive need that can seem like a huge gorge that doesn't have a bridge available for everyone to cross. But I don't see it that way, and neither does ISDH. ISDH is contemplating what our state can do to arm everyone with the education necessary to meet the needs identified. Joy and I are alongside them, making strong recommendations about how we can educate folks and presenting options to foster prevention and safe and effective care for Indiana's healthcare consumers. I'm proud to say that when any of the 100 facilities that are participating have a WOC nurse, that nurse has been a strong leader for that organization in our initiative.
What about you? Is your state engaged in an initiative you can contribute to? Or, if there isn't one, are you the change agent your state is waiting for? You may hold the key to the solution that your facility or community or state is looking for.
In Indiana, we will prevent pressure ulcers. We will know the facts. We will take action.
Will you?
