By Bill Richlen, PT, WCC, DWC, and Denise Richlen, PT, WCC, DCCT
How many times have you heard someone say, “I didn’t know PTs did wound care”? Statements like this aren’t uncommon. The role of physical therapists (PTs), occupational therapists, and speech therapists in wound care is commonly misunderstood by and even a mystery to many clinicians. Sometimes the therapists themselves are confused about reimbursement or what their role on the wound care team can be.
Including rehab therapists on the wound care team is vital to a successful wound care program. If there is no active therapy involvement, patients won’t receive the benefits that rehab interventions can provide to help heal wounds. In addition, facilities that don’t foster active therapy involvement in the treatment of wounds will lose the opportunity to increase their revenues and save money. In a world where the incidence of chronic wounds continues to rise as the population ages, the use of the skills of the rehab team in conjunction with appropriate nursing and dietary interventions will improve overall patient outcomes.
Begin with engagement
To make the rehab staff part of the wound care team, the first priority is to engage them in their roles related to wound care.This may require education and guidance, as there may be a skills gap; comprehensive wound care education isn’t necessarily part of the curriculum for therapists in their college programs, and therapists may not have had wound care experience during their clinical internships. This lack of training puts therapists at a disadvantage and may make them reluctant to participate in wound care. It’s important to start the conversation and help therapists see where they can make a real difference in their patients’ lives.
The primary question concerning rehab is this: Is the service skilled or nonskilled? Skilled therapy service is defined as one that’s medically necessary and that requires the intervention of a therapist.
Appropriate use of the different therapy disciplines can provide significant wound healing benefits for the patient. Physical therapy skilled services related to wound care include such interventions as wound debridement, modalities (for example, electrical stimulation, ultrasound, and diathermy), edema management, positioning, orthotic use, and mobility. Occupational therapy can provide edema management, wound debridement, positioning, toileting programs, self-feeding, and wheelchair management. Speech therapy can address cognitive deficits, swallowing or chewing dysfunction, and nutrition management.
Financial benefits Financial implications of using rehab staff in wound management comprise increased revenues and cost savings. Depending on the care setting, revenues from the use of rehab staff can increase in various ways:
• Acute-care/hospital setting: Diagnosisrelated group (DRG) reimbursement will improve.
• Long-term acute-care setting: DRG reimbursement will improve.
• Skilled nursing facility/long-term care setting: Resource utilization group levels with Medicare A patients and Medicare B and private insurance billing will improve; case mix index will increase.
• Home health setting: Service utilization and home health resource group scores may increase.
• Outpatient setting: Third-party reimbursement may increase.
As impressive as these possibilities sound, a clinician once commented after hearing us present on this topic that all we had done is effectively increase the bill. Therapy should be seen as a return on investment rather than a cost.
When dealing with the challenge of healing chronic wounds, one can’t be a short-term thinker, especially in regard to the cost of different treatment interventions. Pinching pennies in the short term (using “cheaper” treatments to save money) generally leads to increased healing times, which ultimately lead to higher overall costs—not to mention a lower quality of life for the patient who has to endure an open wound for a longer time.
Many chronic wounds have an increased healing time because the basics of wound healing haven’t been addressed, including effectively treating the cause of the wound; managing the bioburden; managing exudate; promoting appropriate moist wound therapy, efficient removal of the necrotic burden, and appropriate nutritional interventions; and ensuring good tissue perfusion.
The ineffective and inefficient addressing of the basics of wound healing can be attributed to a lack of education and knowledge of current wound care approaches among clinicians. A proactive rehab team can address many of these basic factors and essentially increase the speed at which wounds will heal, thereby lowering the overall costs of wound care, because the longer the healing time, the higher the cost to the facility.
Key management skills
How exactly can a rehab team decrease healing times and lower the costs of wound care? Effectively managing necrotic tissue is an integral part of moving the wound from an inflammatory to a proliferative healing phase. Physical and occupational therapists are able to debride necrotic tissue through conservative sharp debridement, application of biological debridement, and the use of modalities at a fraction of the time required by enzymatic or autolytic debridement methods.
It’s important that each discipline verifies whether its scope of practice allows its therapists to perform sharp debridement, as this parameter can vary from state to state. Physical and occupational therapy can provide modalities, such as high-voltage galvanic electrical stimulation or diathermy, that can increase circulation, decrease pain and healing times, and increase the comfort and quality of life of the patient. In addition, electrical stimulation and diathermy have bactericidal properties that can help manage the bioburden in a wound.
Removing the cause of wounds is essential to their healing. For example, physical and occupational therapists can perform ankle-brachial index/Lanarkshire oximetry index, then safely choose and apply compression bandaging systems inconjunction with massage techniques that can remove edema associated with venous insufficiency and lymphedema.
Physical and occupational therapists can also assess for positioning limitations and educate patients and staff in effective positioning methods that can prevent continued pressure to the wounds and further tissue breakdown. Physical therapists can assess the feet of patients with diabetes for deformities and high-pressure points. Performing a gait analysis can contribute to the proper use of effective offloading footwear and devices to allow neuropathic ulcers to heal and prevent future ulcerations.
Effective nutritional interventions can accelerate the proliferative phase of healing. Occupational therapists can assess the patient’s ability to self-feed and consume adequate amounts of protein and other nutrients needed for wound healing. Speech therapists can assess chewing dysfunction and dysphagia that impair the patient’s ability to chew and swallow these nutrients, leading to dietary recommendations to improve the patient’s overall nutrition. A speech therapist can also assess for cognitive deficits and educate the patient, family, and staff on how to effectively work with the patient, including ways to increase the patient’s nutrition intake.
Rehab therapists play a wide variety of roles to assist the wound care team in the overall care of wounds. Their expertise and skilled services can exert a significant impact on the cost and reimbursement associated with managing wounds. Developing your rehab staff’s understanding of wounds and their role as part of a multidisciplinary wound care team will improve outcomes and patient quality of life.