Aria Home Health, Inc.

Aria Home Health, Inc.


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Wound Care and Home Care

Introduction

This article will discuss factors affecting appropriate use of home care nursing for wound care. Numerous factors affect selection of patients and wound care strategies, such as wound characteristics, family support, and Medicare and Insurance guidelines.

The first question to consider for wound care in the home is eligibility. For a patient to be eligible for home care through Medicare, they must be "Homebound." This means that they do not routinely travel to run errands, visit, etc. They are able to visit their doctors. Private insurance and workers compensation are often not as restrictive. Home care agencies have no choice but to dismiss Medicare patients who they find are not truly homebound.

The next question that arises is when is a patient a candidate for home care? For patients leaving the hospital, I consider them candidates from the wound standpoint for home care when the wound will no longer require much if any debridement and have shown some improvement in healing such as granulation and contracture. For patients seen in the wound center the question that arises is when can they stay at home vs. need to be admitted to the hospital. This is a judgment call, but the factors we look at that favor hospitalization are cellulitis or other signs of infection requiring aggressive IV antibiotics, need for significant debridement, poor control of other medical problems such as diabetes, or a sudden worsening of the wound.

Selection of dressings is perhaps the most difficult issue of all in home wound care because it involves wound specific issues as well as financial and practical considerations. The ideal dressing for a wound care patient is one that can be changed only every other day or less. It is not practical to try to do BID or TID dressings at home unless the family can help. Another problem encountered is with chronic wounds that are not making or expected to make any progress. Medicare views home health services as an interim service and when a condition no longer makes progress it becomes "custodial" and it is expected the family will take over or the patient go to a skilled unit.

There are times when a wound is not completely clean and dressing debridement with a wet to moist type dressing is appropriate, so we try to do these only for short periods of time if frequent nursing visits are needed. If the wound is not clean enough we might perform sharper debridement or use enzymatic agents. We try to incorporate modern moist wound healing principles, which can also be conducive to more occlusive type dressings, which allow less frequent dressings. Although many of the modern wound care supplies cost more on a per item basis than old fashioned wet to dry, their increased efficacy, decreased healing times, and less frequent need for dressing changes generally make them the preferred technique from both a cost and efficacy standpoint. I will discuss modern wound principles of moist wound healing further in the next article. Other future topics include:

  • Modern (Moist) wound healing
  • Malpractice issues
  • Silver containing products
  • Infection in wounds
  • Debridement
  • Heel Wounds
  • Pressure relief for various areas
  • New systemic antibiotics

Matthew Pompeo MD is a General Surgeon specializing in care of difficult wounds. Dr. Pompeo is Wound Care Director of Aria Home Health, Doctors Wound Center, IHS Dallas, and LifeCare Dallas. For questions or comments he may be contacted at Healerone@aol.com.