As medical professionals, we are taught many ways to heal wounds, prevent or limit future problems. We keep educating ourselves as a matter of course; our goal is to be aware of changing best practices, and keep up with the latest in evidence-based medicine.

I went further than that, earning my certification in Ostomy. I wanted to gain the expertise to help patients receive better care though better support. But it seemed as though once a patient left our care, they reported feeling like they were “on their own.” Despite our most aggressive posture in which we tried to provide them things beyond basic healing: education, warnings, and advice, using verbal and written discharge notes and care plans, we had little impact.

It would return with a related or recurring issue, time and time again. Clearly, a new care paradigm was needed and with all the aforementioned in consideration, the solution was self-evident.

The Cycle of Recurrence

It can be frustrating to the patient and caregivers when, a patient with a healed diabetic neuropathic foot ulcer returns to you with the old ulcer now reopened, or a new similar wound nearby. Finding that this recurrence or new wound seemed to take even longer to heal than the original created frustration. More, that patient may require hospitalization from any number of unchecked problems including soft tissue or bone infection or other complication.

These recurrences are frustrating for, the patients, their families and not surprisingly, we professionals. The psychological blow is a hammer to the ego, it’s as if we’ve failed our patients and their loved ones.

The recurrence feels like we’re stuck on a giant hamster wheel: treating, healing, recurring. Not surprisingly,

Ostomates can end up in the same cycle

Approximately 80% of ostomy patients develop peristomal skin issues after hospital discharge. Another 30% of ileostomy patients are readmitted to the hospital setting from dehydration. It is incomprehensible that with well trained caregivers available, that a patient with a chronically leaking urostomy pouch was told by a well intentioned but poorly trained nurse: “Tape the bag to yourself.” The fact that the ostomy pouch was poorly chosen and poorly fitted was not even considered. Imagine if that nurse had recognized that the key was a proper update to a pouch fit, and a clean, healthy site.

Breaking the Cycle

In 2015, the Centers for Medicare & Medicaid Services (CMS) began a program to reimburse physicians for providing certain types of non-face to face care by skilled professionals under their direction. One of the goals of this plan was to provide a financial reimbursement to support a Chronic Care Management (CCM) plan for patients receiving care for two or more chronic conditions. Another goal was to try to bring down the number of recurring issues that might be better addressed by providing robust preventative care and monitoring of these patients.

In 2017, CMS expanded and simplified this program. Along with increasing the number of billing codes for CCM services, they simplified the mechanism for providing these services. As a result, Medicare patients with diabetes, and Medicare patients with some type of ostomy qualify for chronic care management services. Services that can break this cycle of recurrence.

Breaking the Cycle for Your Diabetic Medicare Patients

Careline contracts with physicians and other health care providers under this incentivized prevention program. We help you break the cycle of recurrence by extending your reach of care to diabetic patients with:

  • Patient education and compliance verification
  • Treatment oversight and management for existing wounds
  • Prevention through post-wound monitoring

A patient with a diabetic wound, such as a foot ulcer, begins working with us as part of your treatment plan for the wound. We communicate daily with the patient to educate them, train them in self-care, and to verify treatment compliance.

After their wound is successfully healed, they aren’t on their own. We keep communicating with the patient, and educate them about recurrence prevention. We continue to verify compliance, per your care plan, to prevent new wounds and get them to participate in their plan to manage their diabetes. We monitor on a daily and weekly basis for any signs of wound recurrences and/or uncontrolled blood glucose levels.

If concerning issues are identified, we immediately notify the patient’s primary physician. Related actions can be ordered or required much sooner, rather than far too late.

Breaking the Cycle for Your Medicare Ostomy Patients

With ostomy patients, Careline assists before and after surgery, helping your staff set up and manage an appropriate and robust chronic care management for each patient.

Careline Consultants assure that the integral parts of a successful ostomy outcome include:

  • Stoma markings
  • Proper education for the patient and family during all phases of the procedure
  • Coordination of discharge planning with medical supply companies, home health agencies and family
  • Aftercare provided by trained nurses
  • Post-surgery education for the patient and family on the ostomy, diet, lifestyle changes, and complications

Careline’s goal is to create a solid care continuum. Your partnership with Careline creates an easily achievable reality. For Ostomy patients, we support your care and provide additional education. We assist in identifying and creating logical anatomic stoma markings. We act as a backup or primary source for education and monitoring. We are available for questions from the patient or family.

Careline is a Bridge Between You and Your Patients

Careline is not a home health agency. We do not perform telemedicine, and do no case management. We comprehensively provide services that allow physicians to increase involvement in the day to day care of patients who meet CMS criteria without having to increase in-house staff.

Our involvement is always dependent upon the primary care provided in the hospital, by home health care after discharge, and can continue long after traditional services are terminated.

Our compensation comes solely from a partnership with physicians and other providers. We comprehensively assist the chronic care management you provide to your patient population. This work, reimbursed by CMS, provides you with an additional revenue stream from your current patient population.

Our goals are simple:

Prevent new diabetic related ulcers and other related issues via managed diabetic care, while providing treatment oversight and management for those who present with existing wounds.

Provide support before and after ostomy surgical events, prevent complications, and improve the patient’s quality of life.

This paradigm of care we help you provide for your diabetics and ostomates is not new. But with our partnership, it is more achievable. We help you provide care that can focus greater emphasis on prevention of problems and maximizing quality of life.

Contact us to see how we create expand your services into a wide spectrum of care and prevention for your Medicare patients.

To your health,

For more information, call us toll-free: (800) 928-6036