Dear CMS: Where's the Change? Can We Help?

O

n January 23, 2007, our nation’s “Long-Term Budget Outlook” was presented by David M. Walker, the Comptroller General of the Government Accountability Office (GAO). In his testimony,¹ Mr. Walker reported not only that our nation’s current fiscal path is unsustainable but that future crises will be compounded by the inevitable change in our nation’s demographics. As the Baby Boomers leave the work force, Mr. Walker predicts that the growth rate of our Gross Domestic Product (GDP) will decline, as healthcare costs continue to increase. At the same time, entitlement expenditures associated with Social Security and Medicare/Medicaid will increase significantly.
       These rising healthcare costs combined with increases in entitlement spending and a drop in overall growth rate, compounded by the current budget deficit, will ensure that our children inherit a government that in their lifetime “does nothing more than pay interest on its debt and mail checks to retirees and some of their health providers.” Mr. Walker also reported that these financial demands will lead to national crisis if significant change is not made. And he recommends for this change to start now.
       I am a geriatric nurse practitioner (GNP) and certified wound, ostomy, and continence nurse (CWOCN). I have been working in long-term care and have a specific interest in promoting cost-effective, evidence-based wound and continence management strategies to support implementation of Centers for Medicare & Medicaid (CMS) federal tags F314/F309 and F315. From a WOCN perspective, these are excellent tags that blend experience and research into quality goals of care. However, my concern is that over the past few years, I have seen very little resulting change. The issue seems to be that the science in these tags is not well understood at the frontline. Any evolution that has occurred surely will not answer the crisis call of the GAO.
       In my opinion, we need far more than interpretive guidance to make the necessary changes in practice. We need education, motivation, and application. We need to become practical. Nursing home providers know the mandates, but they don’t always have access to the “how.”
       For example, I’ve seen that it’s not clearly understood that reusable chux need to be changed soon after the resident voids, since these products simply catch moisture but do not protect against moisture damage once they are wet. If one does not understand these principles, the information will not be applied to achieve better outcomes. I have seen inappropriate use of prophylactic antibiotics as first-line treatment for recurrent urinary tract infection (UTI). Not everyone understands that restoring acidic vaginal pH can decrease the risk for recurrent UTI in a postmenopausal resident. Everyone knows that ulcers must be healed, but not everyone understands that silver is a chelating agent that can inactivate the debriding action of papain urea. If a resident has a sacral pressure ulcer, repositioning from left to supine to right is not appropriate. Pressure should be kept off of the ulcer for uncomplicated healing to occur. A stasis ulcer requires compression to heal and stay healed. The implications of peripheral arterial disease are not always understood. One must consider plantar foot sensation in residents with diabetes and not put lotion between the residents’ toes.
       Quality Improvement Organizations (QIOs) could provide needed education, but is it realistic to expect them to have a thorough understanding of the specialty science of continence and wounds? The state survey team could provide the motivation, but this involves understanding of scientific information that specialists invest significant time and effort to acquire. Is it realistic to expect a survey team to reliably provide a timely critique? Without focused education and timely motivation, how can there ever be evolution of cost-effective application? We WOCNs would love to help.
       We currently pay more money for lower-quality healthcare than any other developed nation. One might argue that our healthcare system has been functioning in a vicious cycle. Errors and oversights lead to lawsuits, which lead to increased cost of malpractice insurance, which leads to demand for increased wages, which leads to higher cost and dissatisfaction, which results in calloused attitudes and a faster work pace to make more money—and after all of that, we end up with more errors and oversights.
       If we are to answer the call of the GAO, then we do not need new mandates or a more complex network of guidelines as much as we need to learn how to apply the guidelines we have. There is a gap between theory and practice, and WOCNs can help. The WOCN’s frontline practical experience and specialty understanding can help to promote necessary change. That change should start now—it need not wait for the Baby Boomer crisis.

       Editor’s note: This is the debut of the “Commentary” department, which is an outlet for authors and readers to discuss hot topics in long-term care in a more informal and opinion-based style. To comment on this topic or express an opinion on another, please contact Managing Editor Ryan Dougherty at ryand@hmpcommunications.com.