“I’m a Physical Therapist working in homecare for four years. The agency I’m employed by is considering having PTs perform wound care in response to the recently enacted 2008 New Rule PPS reforms. I’ve had minimal wound care training and experience in my professional education or any subsequent employment positions. I’m concerned that my skills will not compare favorably to those of experienced or certified wound care nurses. I’m also unsure as to how to view wound care based PT visits in contrast to the standard rehab visit focused on the concept of restoration of function. Has CMS provided any specific guidelines in this area?”
I share your concerns and feel they quite accurately identify some questions that will surface as increasing levels of wound care visits are performed by Physical Therapists in the area of Medicare home health. Many agencies are moving in the direction of PTs providing wound care in the home, some as a response to the loss of the previous high therapy threshold of 10 rehab visits. Though Physical Therapists have historically performed wound care in other health care environments (acute care, sub-acute rehab, etc), the connection has primarily been linked to the role PT plays in the area of hydrotherapy. The application and use of whirlpool is a well established and vital component in the acute care treatment of wounds. The circulatory benefits of hydrotherapy, in addition to the topical debridement often seen during this treatment, are well documented. Some health care providers, particularly teaching hospitals, have historically emphasized the role of PTs in wound care and as a result, have developed many therapists proficient in wound treatment.
When examining the issue of wound care provided by PTs in home health, many different perspectives can offer valuable insight into this issue. It is accurate, from the point of the Physical Therapy profession, that PTs have provided some level of wound care in many different treatment environments prior to home health. Wound certified PTs are practicing in almost all areas of the country and provide positive contributions to patients in need of this modality. Certainly, some Physical Therapists have much to offer in the realm of wound care and treatment and are justified in their beliefs that they represent a clinically viable alternative to nursing as wound specialists. Two major areas of concern come to mind, however, when marrying these realities with PPS home health regulations, particularly the 2008 New Rule reforms.
First, the issue of acceptable levels of expertise amongst the various PT personnel participating in the delivery of home health visits that would include wound care activities is of some concern. Though the appropriateness of a Physical Therapist with Wound Certification is quite obvious, it seems likely that some agencies (or their administration) might not cling to such credentials as a pre-requisite for assigning wound care responsibilities to a lesser qualified PT professional. Though this represents one man’s opinion, I remain concerned about levels of quality care delivery regarding wound treatment and clinical outcome results.
Second, the issue of appropriate therapy utilization immediately comes to mind. With the gaming aura that has enveloped home health therapy delivery since the advent of PPS (as a direct result of the profitability associated with the now revised 10 visit high therapy threshold), many providers feel no reluctance to increase HHRG-based reimbursement levels by maximizing therapy visits IN ANY WAY POSSIBLE. Though CMS has made no specific statements regarding this issue, it seems unlikely to this author that Medicare would continue to provide increased levels of funding so that PTs may provide wound care when a nursing-based delivery would offer favorable comparative cost savings.
Despite industry wide rumors of large corporate providers moving specifically in the direction of increasing their emphasis on PT wound care treatments, home health agencies should approach this issue with relative caution. The preponderance of 20+ visit programs would certainly bring some unwanted audit attention from CMS. Many homecare providers currently struggle with basic rehab service delivery and outcomes in the obvious areas; transfers, bathing, ambulation, SOB, etc. It seems clinically unnecessary to further cloud these delivery issues by adding wound care to the list, especially when nursing may provide a comparable level of competence without increasing costs to Medicare.
Arnie Cisneros is a physical therapist with nearly 25 years of home care experience. He is the owner of Home Health Strategic Management in East Lansing, MI, providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule.