Leveraging Technology to Reach Your Hospital Wound Care Goals

Think about the terms you hear most often in healthcare. Whether reading a trade magazine, attending a conference, or from internal leadership, chances are the term at the top of your list is “value-based care” (VBC). 

It’s easy to see why – anything that claims to help increase quality and efficiency while lowering costs is akin to the holy grail for our industry. From cost considerations to patient outcomes and fair reimbursement, stakeholders across the healthcare spectrum are looking for ways to leave behind the market-driven fee-for-service models of the past and come up with a workable solution that will deliver on the promises of VBC. 

If there’s a ray of sunshine on the proverbial cloudy horizon, it’s in the ability of today’s innovative technologies to tackle and address the many challenges ahead, from creating necessary efficiencies, to engaging patients to providing essential data-based insights and reports. 

We’ll need all that and more. We still have a lot of obstacles to overcome. There have been few wound-care-specific VBC programs to date and, therefore, not a lot of guidance on best practices. The lack of focus and data leads many of us to ponder how to proceed and, understandably, with lots of questions. 

So, what will building successful VBC programs in hospital-based wound care entail? What are the issues facing in- and outpatient settings? What actions can we take now to unlock the full potential of VBC? And, of course, with many interpretations in the market today, what exactly is VBC? To understand this seismic shift in the healthcare industry and develop the insights to adapt, we must commit to: 

• Understanding the historical context of VBC 
• Examining the current VBC landscape 
• Recognizing and addressing challenges 
• Embracing innovative technologies like specialty EHRs and AI 
• Charting the path forward 

VBC:  Ready or Not, Here it Comes

Despite efforts by the federal government and large managed care plans, nationally, VBC is still in its early stages across many healthcare specialties, not just wound care. Although some working models exist, efforts to encourage widespread adoption across all settings have sometimes met resistance. And, of course, the pandemic didn’t help, slowing down early-stage initiatives at many facilities.

But there’s a growing sense of urgency to move the model forward. The Centers for Medicare and Medicaid Services (CMS) aims to transition all Medicare beneficiaries to some form of value-based care payment solution by 2030.ⁱ Other payers – commercial and public – are in various phases of following suit with the next few years promising significant investments and initiatives from a wide range of stakeholders. Leading industry insiders like McKinsey predict that the number of lives covered will double by 2027.²

External forces aren’t the only factors influencing the growth of VBC programs. Leadership at hospitals, health systems, and other organizations recognize that within the context of evolving healthcare models, leveraging innovative solutions is critical not only for enhancing patient outcomes and the overall quality of care but also for the financial survival of their organizations. 

This brings us to wound care. . . while there are VBC programs covering a wide range of chronic conditions, including kidney and heart diseases, there are few for wound care. It’s time to rethink that paradigm and see how our part of the healthcare delivery system can more fully participate in, and contribute to, value-based programs. 

Because of the conditions involved, as well as their scope, there are tremendous opportunities for VBC in wound care. Consider the impact of Hospital Acquired Pressure Injuries (HAPIs), venous ulcers, and amputations associated with diabetes; all of these directly relate to crucial VBC issues such as quality, outcomes, readmissions, and more. 

The History of VBC: How We Got Here

The roots of VBC go back decades to the Pay for Performance (P4P) and capitated models of health maintenance organizations (HMOs). The early 2000s witnessed the emergence of value-based purchasing initiatives led by organizations like the Centers for Medicare and Medicaid Services (CMS). These programs began to tie financial incentives to care quality, paving the way for broader value-based reforms. In 2006, the VBC term gained traction when Michael Porter and Elizabeth Olmsted Teisberg introduced it in the groundbreaking book, “Redefining Health Care.”ⁱⁱⁱ

VBC programs further evolved from the Patient Protection and Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Both before and after that milestone, other programs that incorporate and encourage the principles of VBC have been implemented.^iv For example, Medicare’s Shared Savings Program in 2012 (before) and CMS’s Primary Cares Initiative in 2018 (after). What’s more, the model is continuously updated and revised with new guidelines.  

However, the real drivers of VBC have been the regulatory evolution from within CMS – that’s where hospitals, in particular, go for guidance and updates. The five original value-based programs include:^v 

1. End-Stage Renal Disease Quality Incentive Program (ESRD QIP) 
2. Hospital Value-Based Purchasing (VBP) Program 
3. Hospital Readmission Reduction Program (HRRP) 
4. Value Modifier (VM) Program (also called the Physician Value-Based Modifier or PVBM) 
5. Hospital Acquired Conditions (HAC) Reduction Program 

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The State of VBC Today

While wound care-specific VBC programs seem scarce, a closer examination reveals that many organizations have been developing, implementing, and operating under VBC principles for years. Hospitals with Accountable Care Organization (ACO) or HMO contracts or programs like CMS’s Hospital Readmission Reduction Program (HRRP) incorporate the essential elements of VBC, as they link payment to the quality of care.  

With its emphasis on capitated and bundled programs, perhaps the biggest champion of value-based care is The Department of Veterans Affairs (VA). The world’s largest health system treats scores of wound care patients due to a patient population that encompasses the elderly and wounded. For example, pressure injuries, in particular, impact veterans with spinal cord injuries. Even Congress is trying to address the need to reduce PIs among veteran populations.  The 2022 congressional appropriations bill included funding for the VA to adopt the International Guideline for Prevention and Treatment of Pressure Ulcers/Injuries.^vi (Note: For more on this topic, check out this great article in U.S. Medicine, VA Battles Potentially Deadly Pressure Injuries; Veteran Patients at Higher Risk.)  

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There are great examples beyond managed care and Federal programs. There are also numerous quality initiatives developed in hospital wound care departments that highlight its ability to both 1) support a hospital’s overall VBC initiatives; and 2) lead the way in fully dedicated wound care VBC initiatives. 

The Challenges of Today 

While VBC programs will continue to grow, and all organizations must adapt, there are issues to understand and explore. Historically, wound care has presented challenges due to factors such as the complexity of treating wounds, patient comorbidities, and issues with adherence and compliance. Unidentified wounds upon admission can lead to fines and penalties affecting value-based programs. 

Additionally, hospital-acquired pressure injuries (HAPIs), specifically Stage III and IV PIs, are considered Never Events by CMS. Yet, approximately 2.5 million acute care hospital patients develop PIs each year,ⁱ with around 80% of hospitals facing HAPI-related penalties.ⁱⁱ

And there are a lot of other issues hospitals must address, including:

• Social determinants of health (SDOH) significantly affect a patient’s likelihood of acquiring chronic wounds and their healing ability. Medicare VBC place strong emphasis on SDOH programs.
• Health equity, including how to reach traditionally underserved and hard-to-serve populations and those in rural areas.
• Workforce challenges, driven by economic factors and impacting hospitals’ ability to staff their facilities fully, affect wound care quality.
• Adoption and utilization of advanced wound care technologies have advanced in recent years but have yet to be used widely and consistently within organizations and even departments.
• Objective outcome assessments, including defining when a wound has healed and addressing past inaccuracies in Evaluation & Management (E&M) measurements with digital imaging software.

Ensuring these very real issues are factored into and addressed within VBC programs will require discussions with CMS to ensure realistic VBC guidelines. Additionally, it will require operational adjustments within a hospital’s program. For instance, enhancing wound assessment through digital technologies can provide more accurate measurements, which is crucial for a successful VBC program. However, because there are significant variations in measurement accuracy with digital vs. manual measurements – up to 44% – it will be critical to develop new processes when using digital technologies – such as determining the overall size of a wound by using length x width. This will ensure that baselines are accurate and consistent when healing rates are compared for VBC quality and reimbursement purposes.

While there are reasons for optimism, according to Kevin Keenahan, Chief Product Officer at Net Health, we’ve got more to do to realize VBC’s potential fully. “Consider a 75-year-old patient in the hospital for heart failure with multiple comorbidities and a pre-existing PI,” he explains. “Guidelines may say the patient should heal within six weeks.  Considering her overall health status, wound care professionals know it’s much more likely to take double that time. Scenarios like that – where the complexity of a patient’s status isn’t factored into the metrics – present a nuclear bomb for the industry.”

Keenahan believes that various VBC models will ultimately evolve, including incorporating wound care into capitated payment programs, expanding HARP programs, and ACO models.

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Role of VBC in Outpatient Programs 

Currently, most VBC hospital programs are focused on acute settings. But there are many opportunities for hospitals with outpatient wound care programs as well, especially when part of bundled or capitated programs. For example, outpatient programs can highlight specific quality metrics that can be part of quality reporting programs to earn incentives and avoid penalties achieved, such as: 

• Wound healing rates 
• Infection rates 
• Patient satisfaction  

Additionally, the expansion of hospital-at-home and home health initiatives gives opportunities to use digital technologies for a wide range of priorities deemed as crucial by CMS and other payers for VBC, including: 

• Engagement  
• Assessments  
• Access 
• Patient-Centered Care 

From EHRs to AI: The Role of Technology  

What do all wound care programs have in common, regardless of setting, patient population, size, or location? To deliver high-quality care, optimize operations, and demonstrate results in today’s data-driven, value-based payment landscape, healthcare providers and industry partners need advanced wound care technology. 

Effective quality programs begin with specialty-specific electronic health record (EHR) platforms. These solutions play a critical role in VBC and quality initiatives by promoting productivity, efficiency, and consistent wound measurement management, eliminating subjectivity and leading to better outcomes. 

Here are additional important features that technology used in VBC programs should possess: 

• Strong wound care specific data gathering and reporting. The cornerstone for a strong VBC program is a robust wound-care specific database that can help provide insights, analysis, and necessary reports. 
• Automated wound measurement capabilities. Accurate measurement of wounds is essential for any quality program. The best solutions reduce the wound measure error rate by 90% or more.  Look for solutions that integrate easily into your EHR and will be simple for staff to learn and use. 
• Focus on workflow. VBC programs will only succeed if they are built with the workflow of the wound care team in mind. They must be seamless and give more time for hands-on patient care by eliminating repetitive tasks. The best technologies will facilitate this goal, often reducing the time required to perform routine tasks by two or more hours per day. 
• Efficient documentation. Documentation outlines when, where, why, by whom, and the specific steps taken in the treatment process. It helps ensure all steps taken are documented, which becomes the foundation for reimbursement and reporting on quality initiatives.  
• Digital wound care platform. One of the more transformative innovations in would care has been the use of smart devices to take and share wound images. To be truly effective, the tech must seamlessly integrate with EHRs and offer dashboard visibility to enable department managers to easily monitor wound evaluation status, including the number healing, improving, and deteriorating.
• Machine learning capabilities. AI and machine learning are the next frontier in wound care. It offers providers a wide range of insights, including the ability to predict chronic wound healing time. A notable study in Advances in Wound Care highlighted the benefits of wound care programs incorporating such technology, which looked at risks associated with wounds not healing within 4, 8, and 12 weeks. Study authors found that days in treatment, wound depth and location, and wound area were the most influential predictors of wounds at risk of not healing.^xi

Considering ROI 

Discussion of any new program, process, or procedure in hospitals is not complete without exploring cost and return on investment (ROI). The potential for wound care programs to support financial goals is significant. 

For example, using advanced digital wound care platforms, a large hospital system in the mid-Atlantic reduced HAPIs – a core component for VBC programs – by 83% and reduced costs from $3.6M to $700k over 6 months.  

Other examples that help to demonstrate how wound care can contribute to hospitals’ overall quality and VBC initiatives while helping the bottom line include: 

• After deploying a global surveillance tool for pressure injury prevention, one health system avoided two HAPI lawsuits with estimated litigation costs of $435,000. 
• A 650-bed hospital with a 5-star CMS rating launched a comprehensive pressure injury prevention program and reduced PSI-03 scores by 50%. (Note: The PSI-03 metric is defined by CMS as the total number of pressure injuries of stage III, IV (Never Events) or unstageable divided by the total number of eligible discharges multiplied by 1000.) 
• A major regional hospital streamlined workflow by 57% – saving providers 2.5 hours/day and enabling the department to see an additional 1.2 patients per day, thereby creating efficiencies that also contribute to VBC. 

A Path Forward for VBC 

While the path forward will continue to present opportunities as well as challenges, one thing is clear: the wound care industry must work together to ensure the promise of VBC is reached. “Wound care professionals juggle so many challenges during the workday, leaving little time beyond patient care and administrative tasks,” said Shellee Lazar, M.D., a wound care physician in Southern California. “I know it’s challenging to think beyond our jobs, but we must also grasp the changes happening in our field. Value-based care will be essential to our survival to stay relevant in our profession and meet payers’ requirements. Without it, we risk being sidelined in decisions that shape our practice.”  

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Dr. Lazar stressed two necessary steps providers need to take: First, ensure that CMS and payers understand the realities of wound care – either on their own or by supporting wound care associations and industry advocates; and also to encourage hospital leadership to support the technologies and solutions that make VBC viable in today’s wound care programs. “We need the support and understanding of all constituents to ensure that value-based care aligns with chronic wound care realities and that it will be fully adopted by providers and benefit all patients.” 

Communication and education among CMS, regulators, legislators, and industry leadership will also be vital to ensure that attainable, realistic, and meaningful metrics are incorporated into programs.  

Well-developed and implemented quality-focused wound care programs, supported with advanced technologies, can and do benefit providers, payers, and patients alike. We’ve all seen and been part of meaningful and beneficial wound care programs. Let’s take those successes and widen their scope of impact by expanding them to new and emerging VBC models that will benefit all stakeholders. 

Stay tuned for chapters 2 and 3 

Be on the lookout for the next two chapters in our Path to Quality Measurements and Value-Based Care e-Book’s: 1) How SNFs Can Avoid the Pitfalls of Value-Based Care and 2) Steps to Success for Wound Care Private Practitioners. 

References:
ⁱ RevCycle Intelligence, Understanding the Value-Based Reimbursement Model Landscape, December 2023 
ⁱⁱ McKinsey, What to expect in U.S. Healthcare in 2024 and Beyond, January 2024 
ⁱⁱⁱ Harvard Business Review Press, Redefining Health Care: Creating Value-Based Competition on Results 1st Edition, May 2006. 
^iv IMO, The origins of the shift toward value-based care, March 2022 
^v CMS, What are the value-based care programs, September 2023 
^vi US Medicine, VA Battles Potentially Dangerous Pressure Injuries, June 2023 
^vii CMS, Hospital Readmission Reductio Program, September 2023 
^viii AHRQ, Preventing Pressure Ulcers in Hospitals, Oct. 2014 
^ix HFMA, Why investing in hospital-acquired pressure injury prevention technology makes financial sense, February 2021 
^x CMS, Quality Measures Fact Sheet, September 2019 
^xi Advances in Wound Technology, Predicting chronic wound healing time using machine learning, March 2022 

(Note – portions of this article were researched and edited using ChatGPT.)