Filling the Gap; How certified wound care nurses in utilization management improve outcomes in home health care.

Wounds effect nearly 15% of America’s Medicare beneficiaries, many of whom are receiving home care services.  The cost of home health care for patients with complicated wounds frequently exceeds reimbursement received from traditional Medicare and other payer sources. Numerous patients are still referred to home care with orders for daily wet to dry wound care. Managed care visits are reimbursed per visit not per the episode as in traditional Medicare. Two large managed health care insurance companies employ Certified Wound Care Nurse (CWCN) in utilization management (UM) to review and manage the number of visits a patient receives during a 60-day episode. Few home care agencies employ a certified wound, ostomy, continence nurse. The UM/CWCN fill the gap for many agencies by advocating for best practice and fiscal responsibility of products and visits.

Each CWCN manages 20-25 complex wound cases over a one-year period. These cases are reviewed monthly with a second CWCN and UM physician to evaluate progress and collaborate to improve outcomes. These patients have complex needs beyond their wounds, which include multiple co-morbidities, financial concerns, transportation struggles, home safety concerns, and social isolation. Patients are struggling to manage their care independently and determined to remain at home.  Insurance case managers and the clinical team (therapists and social workers) are included to assist the patient to attain their goals. Referrals are made to agency therapists, social workers and medical specialists.

When UM/CWCN’s assist homecare agencies in adjusting wound care treatments and include other disciplines, improvements are noted in wound healing, diminished pain and reduced financial burden.  Responsibility for cost effectiveness lies with all clinicians involved in patient care. Utilization review by experts in the clinical specialty can improve outcomes such as decreased wound infections, decreased rehospitalizations, and improved wound healing.