Working together, hospitals, nursing homes, and home health agencies in New Jersey and in some other states have curbed pressure ulcer incidence and prevalence. Their efforts are likely to serve as models for providers preparing to cope with the development that beginning on October 2008, Medicare will no longer pay hospitals for ulcers that develop under their watch.
The Centers for Medicare and Medicaid Services (CMS) reported recently that 52 nursing homes in 39 states reduced the onset of pressure ulcers 69% by working together on process improvement. The project was coordinated by Qualis Health, the quality improvement organization for Washington state.
In a run-up to its new nonpayment rule, the CMS is requiring hospitals to start collecting data now on secondary diagnoses present at time of admission.
Making hospitals more accountable may cut down on the "blame game" that often occurs among providers when a patient develops an ulcer, said Theresa Edelstein, vice president of continuing care at the New Jersey Hospital Association, which has a program that is widely viewed as the pioneering effort in provider collaborations.
In the fall of 2005, the NJHA decided to bring hospitals and nursing homes together to share best practices—building on two successful collaboratives among NJHA member hospitals to reduce ventilator-associated pneumonia and central line bloodstream infections.
Forty of 80 hospitals, 60 of 350 nursing homes, and 12 of 40 home health agencies in the state eventually signed on to participate in the voluntary, 2-year NJHA Pressure Ulcer Collaborative, which involved monthly conference calls in which best practices, education programs, brochures to distribute to providers, access to a Listserv, and technical support for data collection were shared. Some joined only in the second year.
Participants were asked to hit 95% or better in three strategies: conducting head-to-toe skin assessments on every patient or resident; conducting a Braden Risk Assessment within 8 hours of initial contact; and implementing preventive actions in the first 24 hours on those identified as at risk on the Braden Scale.
In the first year, some participants collected point prevalence data, which counted how many patients had an ulcer on a particular day in the month. The second year, they assessed how many new ulcers had developed in a month.
"The data collection was a big challenge pretty much across the board," Ms. Edelstein said.
For providers who submitted data in both years, overall incidence dropped 70% from September 2005 to May 2007—from 18% to 5%. Forty-eight providers reported no new ulcers for 3 or more months. Ulcer prevalence was cut 30%.