Home care agencies face a significant challenge in delivering cost-effective care for wounded patients within the confines of the current Medicare payment structure. Rising supply and labor costs, coupled with staffing shortages, create a challenging environment for providers seeking home health agencies willing to take on complex wound and ostomy patients.

The prospective payment system’s implementation across healthcare settings has led to earlier discharges from hospitals and skilled nursing facilities, often leaving patients in a compromised state. Home care nurses are now tasked with providing specialized care traditionally offered in acute care settings. However, Medicare-certified home health agencies under the Prospective Payment System (PPS) have faced reimbursement cuts, limiting their ability to accept complex cases despite a minimal increase in reimbursement in 2024.

In nearly three decades as a certified wound and ostomy nurse, I’ve witnessed distressing consequences of inadequate wound and ostomy care during the critical transition from hospital to community. Issues include leaving sponges from wound VACs in cavities, improper use of specialized wound products, and a lack of knowledge on proper ostomy care. To address these concerns, the United Ostomy Association of America (UOAA) introduced The Ostomy and Continent Diversion Patient Bill of Rights, offering evidence-based recommendations for best-in-practice quality ostomy care.

DME challenges

Obtaining durable medical equipment has become increasingly challenging due to documentation and face-to-face requirements for proving medical necessity. Patients lacking necessary equipment and wound supplies face complications and deteriorating wound status without the correct resources. Moreover, nurses receive minimal training in wound and ostomy care during their education, complicating their ability to address the unique needs of these patients.

One significant challenge for home care agencies is the high attrition rate among nursing staff, with nurses often staying an average of 1.5 years. Caring for patients in their homes presents unique challenges, from navigating through traffic in metropolitan areas to driving long distances in rural areas. Home environments vary widely, with some requiring care in cluttered and unkempt quarters, adding stress to an already demanding job. Safety concerns, both in terms of the neighborhood and the home itself, further contribute to the taxing nature of providing care in a patient’s residence.

To address these challenges and improve the likelihood of home care agencies accepting wound and ostomy patients, a three-pronged approach is needed:

  1. Patient and caregiver education: Educating patients and caregivers before the home care referral is crucial. Emphasizing their integral role in wound and ostomy care empowers them to provide better care and contributes to improved outcomes.
  1. Systemwide education and standardization: Implementing systemwide education ensures everyone involved understands the role of home care, required nurse visit frequencies and specific skills needed to manage complex cases. Improving the training and skills of home care nurses is essential for consistent and effective care.
  1. Continuity of care and case management: Establishing continuity between different care settings with dedicated care managers is vital. These professionals can facilitate communication, engage with patients, and ensure a seamless transition, promoting a more holistic and patient-centered care model.

In a recent case, I provided consultation to a quadriplegic patient in his home with a stage 4 pressure injury to his sacrum. His primary care provider stayed engaged, writing necessary orders, supported by a certified wound care nurse facilitating accurate and timely wound assessments. His wife learned and performed the majority of his wound care, including using a wound VAC and obtaining supplies, sometimes not covered by insurance.

The home care nurse visited him weekly, coordinating with the wound and ostomy nurse virtually to keep the treatment plan up to date. The wound ostomy nurse collaborated with the primary RN virtually every two to three weeks, ensuring the wound’s continuous improvement. With antibiotics administered without going to the emergency room, the wound healed without transportation to and from home for clinic appointments.

Recognizing the varying financial and social resources of patients, it’s crucial to tailor approaches based on individual abilities and support systems. Leveraging technology, such as virtual visits and telehealth, can enhance efficiency, reduce costs and promote patient self-care.

Advocating for home care policy changes

In light of the formidable challenges faced by home care agencies, policymakers and health plans must take proactive measures. We urge policymakers to reassess the Medicare payment structure, ensuring adequate reimbursement for the specialized care required. Additionally, we call upon health plans, including Medicare Advantage plans, to recognize the vital role of home care in managing complex cases.

Health plans should invest in home care agencies and establish reward systems for those demonstrating positive outcomes. This includes preventing rehospitalization, showcasing sustained wound improvement and overall competence within the scope of practice. By incentivizing and rewarding agencies excelling in caring for complex wound and ostomy patients, Medicare and health plans can contribute to improved outcomes and a more sustainable healthcare system. Let us advocate collectively for policy changes that prioritize and support the invaluable work of home care agencies, ensuring the highest standards of care for those in need.

Julie Roskamp, RN, CWOCN, is head of care delivery for The Wound Company.