Focus On…Wound, Ostomy, and Continence

focuson Wound, Ostomy, and Continence

The case for hiring a wound care professional

Janet Stoia Davis, RN, CWOCN, sheds light on the down- and upsides of partnering with a wound, ostomy, continence nurse consultant

Can your facility afford a wound, ostomy, continence nurse (WOCN) consultant? More importantly, can it afford not to contract with one? WOCN specialists, unfortunately, are not standard in long-term care, primarily for financial reasons. The services of a WOCN consultant are an out-of-pocket, nonreimbursable expense. Although many nursing homes see the need for the services of a WOCN consultant, they usually have not budgeted for them except possibly on a short-term, as-needed basis. Even though an increasing number of WOCNs today are becoming nurse practitioners, which means they may be able to bill Medicare to alleviate some of the financial burden for the organization, WOCNs are still valuable in their own right, and worth considering.

Who Is a WOCN Consultant?
As WOCN consultants, we practice throughout the healthcare continuum in settings such as acute care, nursing homes, clinics, home care, etc. Generally, facilities may have someone designated as a “wound specialist” on staff or may have access to a vendor’s wound care specialist. A WOCN is an independent consultant specially educated, experienced, and certified in the areas of wound, ostomy, and continence care. A WOCN’s training includes not only knowing the standard of care, but applying that knowledge to assist the facility in patient management with cost-effective positive outcomes.

According to the needs of the nursing home, a WOCN consultant can serve in a variety of capacities. Some facilities have the nurse consultant go on rounds either weekly, every other week, or on a monthly basis, while other facilities have the WOCN sit in on committee meetings to review and discuss cases. As a value-added service, the WOCN may also conduct in-services on issues and relevant techniques related to each area of care.

Facilities are becoming increasingly aware of the value of the WOCN consultant. Often we are called in when there is a challenging case-for example, dealing with family issues or a noncompliant patient. I feel that our primary role in the long-term care setting is to teach staff to be more thorough and accurate in documenting care, which ultimately improves care, costs, and reimbursement. Documentation is not limited to local care but extends to documenting all that the facility does to prevent pressure ulcers. In my experience, I find that WOCN consultants are engaged primarily by a nursing home for wound management.

The wound component. Nurse consultants often are used on an as-needed basis, perhaps when the wound is stage III or IV, or if specialized treatment is required for a nonhealing or recalcitrant wound. In addition to the previously mentioned functions of a WOCN, a facility can avail itself of the WOCN’s expertise to conduct an overall evaluation its wound care program. This involves face-to-face interviews with everyone on staff, from nurses to housekeepers to central supply, in order to evaluate how they are servicing residents. Based on observation and interview responses, the WOCN gives the facility a written proposal on how to improve or revamp its wound care program. In some cases, the facility continues to manage the program and implement changes, but other organizations may need to have a WOCN consultant or an outside company spearhead the initiative to make the program run efficiently and cost-effectively.

I take a holistic approach to wound care in my practice. When I’m in a skin care meeting at a facility and we are reviewing cases, I throw out lots of questions. The treatment nurse (who must have good assessment skills) usually presents the wound: whether it is improving, deteriorating, or plateaued. As part of the discussion I may ask: “What else are we doing to promote wound healing?” “How are we relieving pressure?” “Why is this wound refusing to heal?” The next component is to determine if we have documented what we have done. The chart should be a “picture” of what we are doing for the patient. It should communicate our holistic approach. Why are we doing what we are doing, and does it correlate with the standards of care? In this way, as a WOCN I teach not only what to do but how to critically think through the issue.

The ostomy component. In this area, the nurse consultant is generally hired for crisis intervention, perhaps when a facility is having trouble keeping a patients’s pouch in place. If this is required, the nursing home and consultant enter into an agreement with a Memorandum of Understanding, and then the consultant can assess and assist the patient in question. Regardless of the consultant’s fee, the WOCN will save the facility significant dollars in care costs, both in supplies and additional nursing time. The value of patient and family satisfaction, as well as lower staff stress, is known to all in the healthcare profession.

The continence component. Like wound care, facilities are getting a handle on continence issues. Treatment nurses have become more knowledgeable and have benefited from the wealth of literature available and the in-services sponsored by product representatives. Yet with all the improvement, continence consultants are still important in managing difficult cases and helping to individualize programs for patients. Because of their specialization, they keep abreast of new products, technology, and protocols to address this manageable condition and head off complications.

What Makes a Great WOCN Consultant?
All WOCNs have the same specialized education, but how each person uses that knowledge in a clinical setting is what makes the difference. A facility must find the right WOCN consultant. By “right,” I mean that the consultant must be a good fit with the facility in terms of philosophy, culture, and attitude. For example, one facility had engaged a number of wound care specialists over time, but the treatment nurse was resistant to their input. Eventually, I came to the facility to work with this particular treatment nurse. My approach was different. I explained that I was playing the role of a surveyor or a lawyer in a legal case. I wanted to teach her to think about what she was doing so she could explain her actions. Since I was not coming to tell her to do it my way, I developed a collaborative working relationship with her. The improvement in her communication skills to physicians and other healthcare providers, as well as her understanding of the care she was providing, led to better care. As an expert in the field, I know there are many ways to treat a wound, and the best results are realized when treatment results from a collaborative effort among the consultant, staff, and administration working together within the facility’s culture. Ultimately, you have to have the right mix of these elements to reach your WOC goals.

Where Can You Find a WOC Specialist?
The Wound Ostomy and Continence Nurses (WOCN) Society is a professional nursing society. It promotes educational, clinical, and research opportunities for its members. Its Web site ( features a WOCN referral service. This easy-to-use feature can locate a WOCN consultant within a facility’s geographic area. Through the referral service, you can find who is available for consult, what part of the continuum of care they serve, and contact information. In addition, the regional chapters of the WOCN Society are excellent resources for information and programming.

My experience in long-term care has been to focus on setting a realistic goal for the patient in care planning. For example, when there are wounds that are not expected to heal, the goal should then be set with that in mind. As a WOCN, my goal, in collaboration with the facility, is first to avoid pressure ulcer development, and second to show proof, through the documentation of care, that if new pressure ulcers develop they were unavoidable.

Many facilities recognize that although the WOCN consultants’ services are an out-of-pocket expense, their value is enhanced because they provide more than local care and product information. Their services help with survey preparation, aid in comprehensive documentation, decrease citations and, if necessary, assist with legal issues.

In the final analysis, the best benefit is that the patient is receiving quality care; staff is being educated on the who, what, when, where, and why of treatment; and the facility is enjoying the reputation of providing quality care.

Janet Stoia Davis, RN, CWOCN, has been a certified WOCN since 1985 and has been in private practice for 10 years. She is based in Riverside, California. For more information, call Stoia Consultants at (951) 756-2202. To send your comments to the author and editors, e-mail
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