The Role of the WOC Nurse in Utilization Management

Changes in health care reform are providing new opportunities for the WOC nurse to expand into new practice roles. Health care insurers, institutions, and providers must become more efficient in the delivery of quality health care services. As experts in wound care with a keen awareness of evidence-based practice and financial implications of treatment, the WOC Nurse is in a unique position to assume a vital role in utilization management (UM). Utilization Management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption.[1]

              Wounds impact nearly 15% of Medicare beneficiaries and cost $28 billion annually.[2] Over a third of home healthcare patients require treatment for wounds, and nearly 42% of those have multiple wounds.[3] The chronic wound care patient is often negatively viewed as the "problem patient" due to excessive costs and long-term needs. Optimal home health care allows the patient to remain at home and avoid hospitalizations or long-term care placement. The WOC Nurse is uniquely suited to monitor and authorize home care services for complex wound cases.  

              A large Medicare managed care company contracted with a utilization management organization to ensure that home healthcare agencies are delivering reasonable and necessary services. The UM company then hired WOC nurses specifically to review pre-authorizations for skilled nursing visits of wound care patients. By collaborating with the agency’s coordinator, home care nurse, physician, patient, and caregiver, the UM/WOC nurse advocates for the delivery of evidence based treatments and optimization of healthcare resources. Through the WOC Nurse's on-going management, the UM company can improve healthcare outcomes while reducing the costs associated with wound care patients. This unique role of the WOC nurse in UM is proving to be a valuable contribution in the managed care market.

[1] Wickizer, T., & Lessler, D. (2002). Utilization management: Issues, effects, and future prospects. Annual Review of Public Health. 23, 233-54.

[2] Nussbaum, S. Carter, M., Fife, C., DaVanzo, J., Haught, R., Nusgart, M., et al. (in press). An economic evaluation of the impact, cost, and Medicare policy implications of chronic          nonhealing wounds. Value in Health.

[3] Pieper, B., Templin, T., Dobal, M., & Jacox, A. (1999). Wound prevalence, types, and treatments in home care. Advances in Wound Care, 12(3), 117- 126.