Wound Care’s Role in Long-Term Care Facility VBC Programs 

As the healthcare industry escalates its transition to value-based care (VBC) and its many emerging flavors, one setting leading the pack are nursing facilities caring for older people and those with chronic and severe illnesses. In this chapter of Net Health’s Value-Based Care series, we’ll delve into crucial areas for nursing facilities in their quest to embrace new models of care and reimbursement, including. 

  • The impact of chronic wounds, specifically pressure injuries (PIs)  
  • The types of value-based programs of most interest  
  • The role of specialized analytic solutions and wound care technologies 
  • Some steps to consider as you move forward toward adopting or expanding your quality and value programs 

The Many Flavors of VBC

Value-based programs mark a huge shift in how healthcare providers approach all phases of patient care – from what they do, to when they do it, to how they bill for it.  The change is generating questions, debate and more than a little apprehension. CMS states that, “VBC was created to focus on quality of care, provider performance and the patient experience.” The primary goal is to promote CMS’ three-part aim: 1) better health for individuals; 2) better health for populations; and 3) lower costs. While there are specific VBC models created by CMS, there are also a number of alternative value and quality programs it also supports. For example, accountable care organizations (ACOs), pay-for-performance, bundled payments, or patient-centered medical homes were also created to achieve value-based care goals. Nursing facilities may also participate in one or more of these programs. For more information, visit the CMS Value-Based Care Site here.  

Pressure Injuries and Value-Based Care 

The patient population, scope, severity, and nature of chronic wounds make them a significant area for nursing facilities to address. Plus, wounds affect not only patient well-being but also reimbursement, quality, and the outcomes measured under any VBC program.  

Let’s take a look at the scope and impact of chronic wounds. According to the US Census Bureau, one in six Americans is over 65,i a figure expected to nearly double by 2050. As the population ages and experiences chronic illnesses and diseases, many may require extended stays in post-acute long-term care facilities like nursing homes. 

There are more than 15,000 certified skilled nursing facilities (SNF) in the U.S.ii, reports an analysis by the Kaiser Family Foundation. This means there are more SNFs than hospitals. These facilities encompass nursing homes, which are certified to provide two types of care: skilled nursing facilities, offering clinically managed recovery periods following illness or injury, and long-term care facilities, catering to the health care and service needs of residents with mental or physical conditions that do not require skilled nursing care. 

All struggle with the same issues when it comes to PIs. Reduced mobility and cognitive decline often result in residents spending prolonged periods in bed, increasing their susceptibility to developing pressure injuries. Almost 11% of long-term care residents in the U.S. develop a PIiii during their stay, with some facilities reporting rates exceeding 20 percent. JAMA Network Open reports that nearly one-quarter of those admitted to SNFs are readmitted to the hospital within 30 days,iv wound care is often a contributing factor for some patients. 

Treating these injuries is costly, ranging from approximately $20,900 to $151,700 per patient, contributing to an estimated annual cost of $3.3 billion for nursing home PI treatment in the U.S.v 

To address this problem, nursing homes have introduced prevention methods to improve care and lower PI rates. However, preventing and treating PIs still proves to be complicated. For example, even though repositioning is a standard preventive measure for patients at risk for PIs, it’s only done in about 16% of cases because staff worry about disturbing residents’ privacy and sleep, and it can be physically demanding and time-consuming. 

VBC Programs that Apply to Nursing Facilities

The clear implications of issues like this highlight why VBC programs are needed and the important role they can play in improving outcomes and quality of life. 

They are also why the federal government and other payers emphasize value-based programs. Three primary programs that impact nursing facilities under the over-arching value-based care umbrella are:  

  1. The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program, where providers are incentivized or penalized based on their performance over several key metrics– including quality measures on PIs. 
  1. Valued-Based Payment Programs for State Medicaid that measure quality rates, including PIs. 
  1. The SNF Healthcare-Associated Infections (HAIs) Requiring Hospitalizations. The newest program aims to track the rate of nursing home stays that result in acquired infections, such as wounds. 

That second bullet is important to note. While Medicare is a massive program, according to Kaiser Family Foundation (KFF) analysis, Medicaid was the primary payer for 62% of nursing facility residents compared to Medicare for 13% of residents.)vi However, because state programs follow CMS, it helps to explore the SNF VBP Program.  

Here are a few key points to know: 

  1. Purpose: The SNF VBP Program encourages SNFs to improve the quality of care they deliver to patients. 
  1. Measurement: Performance in the program is assessed based on a single measure of all-cause hospital readmissions. SNFs are evaluated on improvement and achievement, with scores based on the higher of the two. 
  1. Incentive Payments: SNFs that perform well receive incentive payments. These payments are funded by withholding 2% of SNFs’ Medicare fee-for-service (FFS) Part A payments, which are then redistributed to SNFs as incentives. 
  1. Inclusion: All SNFs paid under Medicare’s SNF Prospective Payment System (PPS) are subject to the SNF VBP Program. SNFs do not need to take any specific action to be included. 
  1. Additional Measures: Congress has included several measures in the program, including hospital readmissions, antipsychotic utilization, and incontinence. CMS adopted additional measures in the FY 2023 and FY 2024 SNF PPS final rules. For more information, check out these CMS Resources. 

Technology is the Bridge to Effective VBC 

While providers and clinicians in nursing facilities have always strived to provide quality care, value-based programs add further pressure to continue to optimize their care for wound care patients. Having the right solutions and support to drive accurate documentation, reporting, and best outcomes is essential. 

Technologies that can support nursing facilities include analytic solutions, specialized electronic health record (EHR) systems, coding, documentation platforms, digital wound imaging solutions, as well as apps and technologies that facilitate the integration of core features into one integrated solution. 

As we’re specifically exploring technology related to wound care, let’s look at how one technology, digital wound care imaging solutions, can impact VBC programs. Digital wound care platforms are primarily deployed via smartphones or tablets. The top solutions are powered by artificial intelligence (AI) and advanced analytics and are mainly used by providers – although some can be used by patients at home.  

Key attributes of effective solutions include: 

Accuracy and Documentation 

Digital imaging allows for high-resolution, accurate documentation of wounds. It’s essential for tracking the progress of wounds over time, which is necessary for assessing the effectiveness of treatments and interventions. Accurate documentation also ensures compliance with regulatory requirements and facilitates communication among healthcare providers. Plus, documentation becomes the critical record of care provided that CMS and payers require for reimbursement and monitoring. 

Remote Monitoring 

Digital imaging enables healthcare professionals to monitor wounds remotely. This is particularly beneficial for SNFs with limited access to specialized wound care expertise. With this capability, SNF providers can take an image of a wound and send it to an expert wound care physician for analysis. Additionally, traveling wound care providers can bring the technology with them, obtain the images needed during the patient visit, and then upload the data into the EHR. Remote monitoring allows for timely assessment of wound healing progress and facilitates early intervention in case of complications, thereby improving patient outcomes. 

Robust Data 

While all of these are key features, perhaps the most crucial is data – information. Payers and providers must be able to access and understand key performance measures, outcomes, utilization patterns, and more. Data should be historical and real-time to enable rapid interventions, treatments, and care coordination. 

Actionable Data for Optimal Decision-Making 

The next step is to put that robust data to work. Digital imaging generates quantitative data about wound characteristics such as size, depth, and tissue composition. This data can be analyzed to identify trends, patterns, and predictors of wound healing, enabling healthcare providers to make more informed decisions about treatment strategies and resource allocation. 

Efficiency and Time-Saving 

Digital imaging streamlines the wound care documentation process, reducing the time and effort required for manual documentation and significantly streamlining workflow. This efficiency allows nursing staff to focus more on direct patient care, improving patient satisfaction and potentially reducing healthcare costs. 

Quality Metrics and Performance Improvement 

Digital imaging facilitates the collection of standardized wound care data, which can be used to track performance metrics and benchmark outcomes against industry standards. This data-driven approach supports quality improvement initiatives within SNFs, ultimately leading to better patient care and outcomes. 

Integration with EHR 

Digital imaging systems can be integrated with EHR platforms, allowing seamless transfer of wound care data into patients’ electronic medical records. This integration improves care coordination, enhances communication among interdisciplinary care teams, and ensures continuity of care as patients transition between different healthcare settings. 

How can data and reporting improve your VBP programs? 

  1. Benchmarking. The ability to know how your program compares to others nationally and regionally provides insights into goals to achieve and information that can help you report on your progress and help market your program. 
  1. Performance assessment & payment methodology. Information related to VBP program reimbursement, especially when tied to a performance assessment, is invaluable. If there are areas needing help, you’ll know better what to target and their cost. 
  1. Robust reporting & data exports. Real-time VBP Scorecards and provider performance analytics solutions fuel quality improvement programs. Technologies that facilitate dashboard review of data make it easy to access and review data necessary for program enhancements. 

Beyond Wound Care Tech 

Of course, there are a range of features and capabilities any technology used in nursing facilities should offer; one of the most important is interoperability and security. As noted, wound care is a crucial component of VBP programs. Some excellent wound care platforms and digital technologies are on the market. However, not all promote interoperability with essential systems, including your EHR and other facility management platforms. Look for vendors that have a proven track record in seamless integration.  

When it comes to security, an important feature is HiTrust CSF Certified vendors. A HiTrust CSF (Common Security Framework) certification indicates that a vendor has met a comprehensive set of security standards designed to safeguard sensitive information. For quality assurance, look for solutions endorsed by the National Quality Foundation. For example, Net Health’s PointRight is currently the only long-term and post-acute care (LTPAC) analytics vendor to have developed NQF-endorsed quality measures.vii 

All of the features and attributes noted require one more thing to be successful: knowledgeable and responsive partners who will use their experience and insights to help you develop solutions, identify needs, and provide guidance and updates on changing rules and regulations – AND how and when to adapt to those changes. 

The Predictive Analytics Sandbox 

One of the more promising innovations in wound care over the past few years has been the introduction of predictive analytics. Leveraging predictive analytics enables wound care providers to improve clinical decision-making and business operations, which leads to better patient outcomes, reduced costs, and higher reimbursement, all crucial for successful value-based programs. 

Predictive analytics rely on machine learning algorithms, a form of artificial intelligence, to compare a current situation (either clinical or operational) to past situations and determine what is likely to happen next. Predictive analytics can help providers leverage an astounding amount of data that no human mind, no matter how brilliant, could sift through. 

The algorithms in these analytics can analyze millions of pieces of data in seconds to recommend a course of action that delivers specific and targeted insights providers may never have been able to arrive at on their own. These analytical algorithms can provide suggestions or guidance that leads clinicians and administrators to better results. 

Some of the data points used in predictive analytic algorithms for wound care include: 

  • Wound characteristics such as tissue composition, percentage of slough, eschar granulation in the wound, pain, drainage exudate types, tissue types, dermatitis, induration excoriation, wound size, and body location 
  • Individual patient parameters like history of certain cancers or other diseases, types of diabetes, muscle weakness, etc. 
  • Vital signs at the point of care like blood pressure, heart rate, and weight 
  • Patient demographic information, such as their geographic location and age 

These algorithms also create a “clinician sandbox”, in which clinicians can evaluate “what if” scenarios to see how the application of a procedure could affect the healing trajectory of a wound. These algorithms can, therefore, provide clinicians with insights that improve treatment decisions, shorten healing time, and improve clinical outcome

Value-Based Care at Work: SNF Success Stories 

Even its most ardent supporters will note a need for more outcomes data on how VBC programs perform in SNFs. Yet the experience of individual organizations participating in VBP programs, especially those utilizing proven specialty technologies, shows great promise. 

One of the programs noted as a gold standard for state Medicaid VBP programs is The New Mexico Nursing Facility Value-Based Payment (VBP) Workgroup. The group was formed to develop an approach to support nursing facilities’ efforts to achieve high-quality outcomes while increasing access to services for Medicaid members. The program’s approach is to support quality improvement based on tiered performance in four long-stay quality measures (antipsychotic use, UTI, pressure ulcers, and long-stay hospitalization). 

The VBP program incorporated leading-edge technologies, including one that used predictive analytics to identify residents at risk and facilitate care coordination within the facility’s care team and with the participating managed care organizations (MCOs) participating in the program. A key goal was to better identify at-risk residents and/or those with special care planning needs for focused intervention.  

For New Mexico, this meant using their chosen technology solution to help identify at-risk patients, predict patients whose conditions could worsen without interventions, and coordinate a targeted care plan to prevent or treat conditions like PIs. The program has worked well, enabling the organization to improve key performance metrics while helping participants manage costs, streamline workflow, and optimize reimbursement. As an added bonus, Star ratings have significantly improved for several participants because of the scope of improvements across a wide range of critical VBP metrics that have been achieved. You can get more information on this VBP success story here

Ready, Set, Put Your Wound Care Program on Go 

Adapting to and successfully participating in today’s emerging VBC world takes knowledge, patience, great technologies, and outstanding partners. There are also important steps the facility can take to ensure wound care programs are properly designed, implemented, and measured, including education, technology integration, and aligning reimbursement. 

  • Educate your team. Helping the care team understand VBC and the role of pressure injury prevention and management is vital to program success. Education should cover risk assessment, early detection, appropriate interventions, and documentation practices. Remember to let your people know how they are doing. Share data and offer opportunities for skills enhancement, peer learning, and regular performance reviews. Integrate your core technologies. 
  • Make sure technology makes life easier. Utilize technology solutions that ensure seamless integration, such as electronic health records (EHRs) with built-in prompts for pressure injury assessment and documentation. Ensure ongoing Outcome Monitoring and Reporting: Track and analyze outcomes related to PIs, including incidence rates, healing trajectories, and patient satisfaction scores. 
  • It’s your data, use it! Identify areas for improvement and demonstrate the effectiveness of pressure injury prevention efforts to stakeholders by analyzing and benchmarking your data. Share data with your team so they can see areas of need and how they’ve improved. (Remember to celebrate and share those milestone improvements!) 
  • Align reimbursement. Ensure that reimbursement mechanisms align with value-based care goals by incorporating incentives for achieving positive patient outcomes, including preventing and managing pressure injuries. Use data on improvements to advocate for fair reimbursement rates that reflect the resources and expertise required to deliver high-quality care. 

It’s Time to Embrace VBP  

Without a doubt, many rules, regulations, and guidelines are required to participate in VBP and other quality programs. However, that doesn’t mean they can be approached via a spreadsheet – by simply looking at the numbers. We should strive to remember that people and their families are behind those numbers. All that we are doing should be to improve their health, outcomes, and quality of life. 

Wound care is crucial to improving the functionality and outcomes that contribute to overall health. Making it a focal point of your VBP program is worth the time and effort.  

However, to reach the promise of VBC programs, we must also look at how we can better align incentives, measure progress, and improve efforts so we can help our patients. Those are realistic and attainable goals. Technology, for instance, is playing pivotal role in driving improvements in care quality, cost-effectiveness, and patient satisfaction.  

There are, of course, challenges to meet. However, by leveraging innovative solutions with trusted partners to provide guidance and support, nursing facilities can make VBC programs work for their organizations, people, and, most importantly, patients. 

Want more insights? Check out the Net Health webinar series.

1 U.S. Census, U.S. Older Population Grew From 2010 to 2020 at Fastest Rate Since 1880 to 1890, May 25, 2023
2 Kaiser Family Foundation (KFF), Total Number of Certified Nursing Facilities, 2023
3 Advances in Skin and Wound Care, Preventing Pressure Injuries in Nursing Home Residents …, October 2020
4 JAMA Network Open, Skilled Nursing Facility Performance and Readmission Rates Under Value-Based Purchasing, February 2022
5 AHRQ, Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed, October 2017
6 KFF, A Look at Nursing Facility Characteristics Between 2015 and 2023, January 2024
7 Press Release, Net Health’s PointRight® Analytics Solution First to Receive Quality Measure Endorsements by National Quality Forum, March 2023