Strength through collaboration

The evolution of the skilled nursing facility (SNF) has seen a shift in its resident population. It’s no longer just a home for those in need of around-the-clock skilled nursing care; it’s now become a short-term stop for those in need of rehabilitation. Hospitals have a very limited window of opportunity to fully restore an ailing patient to his or her previous level of functioning, which often places a significant share of the responsibility on the sub-acute facility.

Individuals requiring additional therapy to regain the necessary strength, mobility and dexterity to return to their home environment are now a significant portion of the SNF population. SNFs are required to complete the transition-to-home process as seamlessly as possible managing any and every obstacle along the way. One obstacle includes caring for acute and chronic wounds. Pressure ulcers, vascular ulcers, diabetic ulcers and non-healing surgical wounds can be a significant deterrent to a successful short-term stay.

Transition to skilled nursing

Residents and families who transition from hospitals to SNFs are facing the daunting task of trying to stay correctly aligned on the hospital’s established path of healing while trying to get answers to questions associated with a new environment. Will the nurses be efficient? How often will I see my physician? How often will I receive therapy? What about my wound care needs? The psychological stress over concerns of continuity of care is tremendous, and things undoubtedly will be much different for the resident even in the smoothest of transitions to a SNF.

The physician, nurse practitioner or wound care specialist who visited the bedside to assess and treat the patient’s wounds in the hospital won’t be traveling with him or her to the skilled nursing facility. The resident must now adapt to a new and more complex method of being seen by those physicians and specialists. What was once a few moments of inconvenience at the bedside in the acute setting is now a time-consuming ordeal that requires the resident to travel to the closest wound care center.

This process requires an often uncomfortable ride to the wound center via wheelchair van, followed by a wait to be seen by the physician. Once the appointment is concluded, the resident often must suffer through additional wait time before returning to the facility.

Unfortunately, the residual effects of the time spent out of the building continue once the resident returns. Valuable missed therapy time must be made up, often consolidated into shorter time spans. It is also very likely that a meal will be missed when someone is out of a facility for a significant span of time.

Although the necessity to travel off-site to see physicians or to have procedures and testing performed is absolute, it is nonetheless very stressful. Individuals with wound care needs are not only trying to heal despite age-related structural changes in the skin; they often are facing personal psychological hurdles. Perhaps residents are the primary caregivers for loved ones at home who are anxiously awaiting their return. Maybe he or she lives alone and is afraid he or she no longer can care for him- or herself. Maybe he or she is facing financial difficulties. Maybe he or she suffered a life-altering medical event such as a stroke or limb amputation.

Regardless of the circumstance, physiological stress responses can have a negative effect on the wound-healing process by slowing it down. A study of 42 married couples by Kiecolt-Glaser and colleagues, published in Archives of General Psychiatry [now JAMA Psychiatry], showed slower healing rates of blisters after they experienced marital conflict as opposed to healing rates when exposed to social support therapy. The overall conclusion of the study was that everyday stressors have a negative effect on wound healing. Residents who become sick enough to require hospitalization and subsequently acquire a wound during the course of that hospitalization certainly will be exposed to significant levels of stress, which is magnified when an additional SNF stay is required.

On-site wound care

Moravian Village of Bethlehem (MVB), Pa., is a SNF that recognizes the special needs of its ever-growing short-term population of residents with wounds. MVB created a 14-bed wound healing unit in 2008 that is designed to manage residents who are trying to rehabilitate physically but also are dealing with complicated wound care issues. The unit creates an environment that fosters healing by staffing it with nurses who are specially trained in the management of complex wounds. It also features a significant number of private rooms that provide for confidentiality during treatments and teaching.

Client response to the unit was significant enough to increase its bed capacity to 22 in 2011. Also that year, the facility took an even greater step when it collaborated with nearby St. Luke’s University Health Network. This collaboration produced a hospital-run outpatient wound center on the campus of Moravian Village, resulting in several improvements for residents with advanced wound care needs.

No missed or altered therapy time. Whenever a resident leaves the skilled nursing facility for any significant length of time, therapy minutes are affected. This absence often results in the resident and therapist being forced to squeeze required therapy minutes into a condensed time frame. Residents often return from an off-campus physician visit only to be whisked off to the gym to achieve the required therapy minutes.

It should come as no surprise that residents often perform poorly when they must do so under duress. When residents are seen on the MVB campus for their wound care needs, the time from the moment they leave their room until their return is 30 minutes or less.

Increased face-to-face physician encounters. It is not unusual that a wound center would request weekly appointments to successfully manage a wound, resulting in a total of four physician/resident face-to-face visits per month. The collaborative effort between MVB and St. Luke’s Hospital enables physician/resident face-to-face interactions to occur not once but twice weekly—once during wound center visits, and a second time during weekly collaborative rounds—resulting in eight total monthly visits.

Collaborative walking rounds occur three days after the initial wound center visit. These rounds are physician-led and include all disciplines involved in the plan of care, including physical therapy/occupational therapy, nutrition, case management and nursing.

Improved nutrition. Residents with wounds are prone to malnutrition and dehydration, which lead to slower wound healing; therefore, meal percentage completion and nutritional supplementation are critical components to their overall care. The on-campus wound center at MVB allows for meals to be delivered and consumed on a routine basis.

Cost savings. The cost of traveling to an off-campus wound center is an out-of-pocket expense and is roughly $50 per round trip. Residents using the on-campus wound center save approximately $200 a month.

The majority of residents with wound care needs at Moravian Village make use of its in-house wound healing program with the exception of those residents with previous ties to other hospitals or wound centers. Residents who otherwise would travel out of the facility often request to be treated on-campus. The top two reasons for these requests are transport costs and the physical toll of traveling.

Measuring success

During 2012 and 2013, 111 non-healing surgical wounds were treated at MVB. A total of 73 wounds were managed on-campus, with an average healing time of 35.9 days. The remaining 38 were managed off-campus, with an average healing time of 42.9 days. Those wounds managed on-campus healed at a 16.3 percent faster rate.

During that same time period, 117 vascular ulcers were managed. A total of 100 were managed on-campus with an average healing time of 40.3 days. The remaining 17 were managed off-campus with an average healing time of 43.7 days. Those wounds managed on-campus healed at an 8.4 percent faster rate.

The healing rate for those residents whose wound care is managed strictly on the MVB campus continues to be shorter than for those who travel to see their physician. The St. Luke’s Wound Management Center at Moravian Village is an example of the type of healthcare outcomes possible when hospitals and SNFs collaborate.

Derrick Lambert RN, BSN, WCC, has managed a 22-bed wound healing unit at Moravian Village, a continuing care retirement community in Bethlehem, Pa., for the past 7 years. Email him at D121463@gmail.com.