Telewound Management: A Model for Value-Based Care

7th Annual GPT TeleHealth Summit March 3rd, 2016

The Wound Problem

The Problem | Overall wound cost & prevalence

Wound Type Cost ($BN) Patients (000’s)

Pressure Ulcer 11.6 2,500 Diabetic Ulcer 13.0 4,000 Venous Ulcer 3.5 600

Increasing prevalence: •  Aging population (10K baby boomers turn 65 each day) •  Increase in prevalence of diabetes and cardiovascular diseases •  8% annual growth

Multiple providers impacted: •  Skilled Nursing Homes •  Home Health Agencies •  Prisons •  Hospices

•  Small, Rural Hospitals •  LTACs •  Capitated or Risk Based Delivery

Models

Pressure Ulcers: •  Prevalence by setting:

•  15% hospital patients •  29% LTC patients

•  2.5M pressure ulcers treated annually at cost of $11B (US) •  Facility acquired pressure ulcers:

•  CMS “never event” •  Hospitals – currently not reimbursed by CMS •  LTC Facilities – not reimbursed beginning 2017 by CMS

•  60,000 US patients die every year from pressure ulcers •  Cost of care ranges from $20K to $150K

The Problem | By wound type

Diabetic Ulcers: •  25% of diabetics develop foot ulcers •  23M diabetic (5% of population) •  Each year 5% of diabetics develop foot ulcers with 1% (>86K ) requiring

amputation at cost of $38K/amputation

Venous Ulcers: •  Affects 600K annually •  $9,600/ulcer to treat •  Equates to $2.5-3.5B annual problem

Surgical Wounds:

•  71.5M surgeries per year

The Problem | By wound type

Home Health •  33 % home health patients have wounds

•  42% multiple wounds •  40% surgical wounds •  25% vascular leg ulcers •  25% pressure ulcers

Hospice •  35% hospice patients have wounds

•  50% pressure ulcers •  20% arterial ulcers •  30% mixed (surgical, stasis, skin tears, & tumors)

SNF •  ≈ 20% SNF patients have wounds

The Problem | By provider

Wound Care is not a discrete medical specialty •  Lack of formal wound management & training •  Decreases access to evidence-based wound care •  Decreases adoption of evidence-based wound care •  Produces large variability in wound care practices

Wound Care practice often relies on: •  Personal experience with wound treatment •  Opinion of colleague(s)

The Problem | No designated specialty

Certified wound care nurses •  <0.2% of all registered nurses •  Nurse treatment time limits effectiveness:

•  On site can treat 5-6 patients/day •  Remotely can treat 15-20 patients/day

•  Annual salary & benefits: $90K Certified wound care physicians (MD, DO, DPM) •  368 physicians in the U.S. •  Wound education: American medical students are inadequately

trained in wound care. * *Annals of Plastic Surgery. 2007 Jul;59(1):53-5.

The Problem | Scarcity of wound specialists

Risk Exposure •  17K pressure ulcer related lawsuits filed annually •  87% of settlements/verdicts reached in favor of the patient •  Pressure ulcer lawsuits in acute & long-term care are increasing •  Judgments as high as $312M

The Problem | Risk exposure

•  Time: •  Dressing changes are time consuming

•  Lack of knowledge & education about: •  Basic wound evaluation/assessment •  Wound treatments & management practices •  Wound prevention protocols •  Use of advanced supplies and treatment modalities

•  Lack of standardization of: •  Wound measurements •  Wound outcomes/metrics •  Wound quality reporting

The Problem | Barriers to wound care

The Problem | High cost of wound care

•  Materials (dressings & therapies): •  Can reduce material costs by:

•  Improving healing times •  Prevention of acquired pressure ulcers

•  Nursing time: •  Dependent on:

•  Dressing change frequency •  Number of wounds •  Associated wound documentation time

•  Can reduce nursing time by: •  Improving healing time

•  Use of advanced dressings •  Use of advanced therapies

•  Preventing acquired pressure ulcers •  Providing streamlined wound software

•  Wound related hospitalizations: •  Can reduce hospitalizations:

•  Using evidence-based best practice guidelines •  Using wound certified clinical experts •  Using advanced wound treatments

Wounds represent 4% of total healthcare costs

Telewound Model

Telewound Model

Increasing access to higher level of wound care Our goal is to HEAL Not just treat

Telewound Model | Pairing technology with wound expertise

TECHNOLOGY Wound Imaging

Video Conferencing Wound Software

WOUND CARE SPECIALISTS

Lower Costs Improved Outcomes Reduced Liability

•  Proprietary Evidence-Based Best Practice Algorithms

•  HIPAA Compliant •  Color-Corrected Wound

Images •  Standardized Clinical &

Financial Reporting

•  Interdisciplinary Wound Care Team

•  Certified Wound Care Clinicians

•  Data Warehouse •  Predictive Analytics •  Costs & Outcomes

Modeling

Telewound Model | Hub for wound care coordination

Hospice

Wound Care Coordination Home

Health

Hospital

LTAC SNF

Clinical Quality

Outcomes

Wound Care Cost Per Patient

Predictive Analytics

Evidence Based

Protocols

Comprehensive Data Warehouse to Drive Evidence Based Best Practices through

Predictive Analytics

Leverage for Value Based Payer Contracts

Telewound Model

Wound Management Software •  Automatic Wound Measurements •  Wound Image Correction •  Wound Image Magnification •  Evidence Based - Best Practice Wound

Treatment Algorithms •  Wound Reporting •  Standardized Wound Metrics

Video Conferencing

HIPAA Compliant

Real Time

CORSTRATA Wound Expert Provider’s Nurse at Patient’s Bedside

Telewound Model | Basics

•  Identify wound etiology •  Etiology drives: •  Treatment

•  Recommend evidence based treatments •  Treatment protocol drives: •  Dressing type •  Frequency of dressing changes •  Advanced treatment modalities

•  Monitor wound progression •  Telehealth wound rounds with facility clinician •  Recommend treatment changes as indicated

Telewound Model | Provider models

Comprehensive Wound Management •  Services:

•  Formulary Review •  Wound Consultations •  Pressure Ulcer Prevention Program •  Staff Education •  Policy & Procedure Review

•  Pricing Model: •  SNF/LTAC = PPD (per patient per day) •  Home Health & Hospice = tiers based on ADC (average daily census)

Wound Consultations •  Services:

•  Identification of Wound Etiology •  Treatment Recommendations

•  Pricing Model: •  Per consult

Telewound Model | Accuracy & patient satisfaction

In-person wound assessment vs. wound image assessment accuracy* •  Literature review indicates:

•  Wound image assessments are accurate for all types of chronic wounds – diabetic foot ulcers, pressure ulcers, vascular ulcers & mixed wounds

•  Direct and electronic wound assessments were similar for slough, necrosis, & granulation tissue

Telewound produces high patient satisfaction* •  According to literature review *Moore Z. et al, eHealth in wound care – overview and key issues to consider before implementation, Published Journal of Wound Care, 2015, 24, S S1-S44.

Telewound Model | Clinical effectiveness & costs analysis

Literature review indicates telewound care*: •  Improves wound outcomes

•  Healing time rate •  % of wounds healed •  Decreased amputations •  Reduced number of hospitalizations

•  Increases effective use of scarce wound experts •  Provides patients access to wound experts (especially for underserved & rural

patients) Literature review indicates that Telewound care*: •  Reduces treatment costs •  Reduces transportation costs •  Reduces wound consultation costs

*Moore Z. et al, eHealth in wound care – overview and key issues to consider before implementation, Published Journal of Wound Care, 2015, 24, S S1-S44.

Telewound Model | Cost analysis

Literature review indicates that Telewound care*: •  Reduces treatment costs •  Reduces transportation costs •  Reduces wound consultation costs Literature review indicates that Telewound care*: •  Reduces treatment costs •  Reduces transportation costs •  Reduces wound consultation costs

*Moore Z. et al, eHealth in wound care – overview and key issues to consider before implementation, Published Journal of Wound Care, 2015, 24, S S1-S44.

The Results

The Results

The Results

The Results

The Results

Telewound Model | Results

•  Reduction in SNF nursing time cost •  Reduction in frequency of daily dressing changes •  Saved nursing time & dollars on average ~ $400/week for a

100 bed facility

•  Reduction in Home Health nursing costs •  Reduction in number of nursing visits (4-6 visits per episode

saving on average ~ $750 per episode) •  Increase ability to educate patient/caregiver for dressing

changes through Telehealth

•  Reduction in treatment associated transportation costs •  Reduction in cost per treatment transporting patient to

wound care center ranges between $500-$700

.

The Results|Diabetic foot ulcers

Diabetic Foot Ulcer (DFU) Prevention Program •  Diabetic patient stratified for risk of DFU &

amputation •  High risk patients:

•  Perform daily self foot exams •  Forward daily photo of feet soles •  Take foot dermal temperatures •  Forward dermal temperatures

•  Daily images & temperatures monitored by wound care expert

•  Images and/or temperatures trigger early

intervention •  Off-loading shoe •  Accommodative dressing

The Results|Advanced wound treatments

Advanced Wound Treatments Designed to: •  Control wound environment for optimal healing •  Maintain proper moisture balance •  Fight infection and prevent biofilm formation •  Protect skin around wound Specialized treatments: •  Stimulate tissue growth and healing •  Enzymatically debride •  Provide substrate for tissue growth

The Results|Advanced wound treatments

New Treatment

•  Revolutionizing debridement of wounds in LTC •  Monofilament technology •  Allows the bedside nurse to debride •  Painless •  Used in conjunction with other debridement

modatlities

Before

After

The Results|Advanced wound modalities

•  Ultrasound debridement •  Negative pressure wound therapy •  Electromagnetic wound stimulation •  DNA guided wound therapy

Biofilm

The Results | DNA guided patient specific wound care

The Results | DNA guided patient specific wound care

Large, retrospective study compared healing outcomes in three large cohorts of wound patients •  Standard of Care (SOC) Group:

•  Traditional Culture •  Systemic ABX

•  Group 1: •  Molecular Diagnostics Culture •  Systemic abx

•  Group 2: •  Molecular Diagostics Culture •  DNA Guided Personalized Topical

Abx

*Dowd S, Wolcott R, Kennedy J, Jones C, Cox S. Molecular diagnostics and personalized medicine in wound care assessment of outcomes. J Wound Care. 2011; 20(5):232-239.

DNA Guided Antibiotics Study

Wound Management | DNA guided therapy

Study 1378 patients; 7 month study period

•  Control (SOC) - (244/503) 48.5% completely closed Group 1- (298/479) 62.4%

•  Group 2- (358/396) 90.4% Time to complete closure (compared to SOC Group):

•  ñ26% in Goup1 •  ñ45.9% in Group 2

Opportunity to heal: •  Patients in Group 2 >200% better opportunity to heal

compared to other two cohorts.

*Dowd S. Wolcott R. Kennedy J. Jones C. Cox S. Molecular diagnostics and personalized medicine in wound care assessment of outcomes. J Wound Care 2011: 20(5):232-239.

Virtual Wound Management for Value-Based Models

Value-Based Models | Types

New care delivery models: •  Accountable care organizations (ACOs) •  Medicare/Medicaid dual eligible state demonstration projects •  Bundled payments:

•  Medicare bundled payment care initiatives (BPIC) •  Insurer (payer) initiatives

•  Other models: •  Shared risk •  Shared savings •  Capitated/episodic payment

•  Readmission reduction programs •  Community based care transitions program •  Adjunct to chronic care management •  State innovation models

Value-Based Models | Prevalence

50% of Medicare spending will be VALUE BASED by 2018

Value-Based Models | ROI

Hospitals: •  Current: Reduction in readmission penalties

Reduction in bed days •  Future: Bundled reimbursement

Home health & hospice agencies: •  Current: Increase in staff capacity (caseload)

Reduction in SN visits/episode Savings on FT wound care nurse Improvement in wound related quality outcomes

•  Future: Bundled reimbursement Readmissions penalties

Skilled nursing facility:

•  Current: Reduction in wound formulary costs Savings on FT wound care nurse

Improvement in wound related quality outcomes •  Future: Bundled reimbursement

Readmission penalties

Value-Based Models | ROI

•  Hospitals: •  Reduce preventable 30 day readmissions for CMS designated diagnoses with

associated penalties (all cause) •  Physicians:

•  Reimbursement for Medicare care management fees §  Chronic care management fee (2015) §  Medicare transitional care management fee

•  Managed care contracts (Medicare advantage, Medicaid, commercial payers) §  Chronic care management fees §  Incentive based contracts

•  Post Acute: •  Increases staff capacity, lowers cost of care •  Increases quality outcomes •  Reduces 30 day hospital readmissions & ER visits •  Care transitions to home •  Bundled payment initiatives

Ancillary Benefits of Virtual Wound Management

Ancillary Benefits | Improved Quality of Life

Chronic Leg Ulcers: •  Improvement in:

•  Pain •  Odor •  Infection control •  Depression

•  Pressure Ulcers: •  Improvement in:

•  Severe pain •  Odor •  Mobility

•  Diabetic Foot Ulcers: •  Reduced fear of amputation •  Improved range of activity

Ancillary Benefits | Workforce

*The National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, 2013 National Workforce Survey of RNs

•  Avg. RN Age = 50 •  % working RNs > age 50 = 53%

Older wound care RNs are attracted to virtual model: •  Eliminates physicality of nursing •  Allows for continued passion to

improve care and educate provider staff

Benefits | Return on investment

Telewound Return On Investment •  Decreases overall wound management costs •  Improves wound quality outcomes •  Improves patient quality of life •  Reduces days to healing •  Decreases number of facility/provider acquired pressure ulcers •  Lowers incidence of wound associated infections •  Generates wound formulary savings •  Reduces need for transportation of patient out of facility or home for

wound care •  Increases competency level of provider CNAs and clinicians

Katherine F. Piette CEO & Founder CORSTRATA Katherine.Piette@CORSTRATA.com (800) 566-1307 www.Corstrata.com