Dr. Jeannine Maguire: Hi, everybody. Thank you so much for attending today's presentation, brought to you by HealHorizon, sponsored by O&M Halyard, in partnership with PAWSIC.
Let me take a moment and share with you a little bit about PAWSIC, the Post Acute Wound and Skin Integrity Council. We are a 501(c)(6) nonprofit. My name is Jeannine Maguire. I'm the current president of PAWSIC. PAWSIC is an interprofessional team that serves as a resource and advocate for all those in post-acute care, whether they are our patients, the caregivers, families, students, or the interprofessional team that cares for those individuals. We offer webinars, education, guidelines and white papers, resources, checklists, and other handouts. Ultimately, we are a specialty group that understands the challenges of achieving skin health and great wound outcomes in the post-acute care space. Check out PAWSIC.org today and join us to be a part of the change.
Without further ado, let me welcome you to today's presentation, From Prevention to Recovery: Empowering Skin Care Strategies for Long-Term Wound Healing Success. I'm so happy to introduce our speaker today, Tara Roberts, another physical therapist, who is the vice president of Quality, Rehab, and Wound Care Services at Nexion Health Management. She is the owner and a consultant of AdvantageYOU HCS, LLC. And now, Tara, I'll go ahead and turn this over to you.
Tara Roberts: Thank you, Jeannine, for that introduction and this opportunity to present today. My name is Tara Roberts. Let's start by reviewing our learning objectives. Describe strategies and models that support skin and wound care program development, sustainment, and ultimately success across the continuum of care and post-acute care. We'll also navigate an individualized skin and wound care regimen tailored to patients at risk for or recovering from wounds. And finally, we'll be emphasizing the role of patient education, communication, and caregiver engagement in achieving the long-term wound management success.
When I think about my experiences with navigating successful skin and wound care programs, I always come back to a primary failure point or gap being our clinicians and how we set them up to succeed or fail. Which brings me to: Where do we begin? In an extensive, ever–changing, and many times complicated clinical service like wound care and wound care programs, I have found that a cornerstone for success to build better outcomes from is focusing on our clinicians who are assessing, preventing, promoting, and providing care day in and day out. Focusing on what we can control is fruitful and creates a clear starting point to cracking the code to successful wound programs. There is no better place to start than with our clinicians. Our clinician performance varies in aptitude, attitude, and application, but through standardization, we can influence and reduce these variations for the better.
A simplified way to approach solidifying clinicians as the cornerstone or foundation for your program is to address the three Cs of skin and wound care. The 3C Framework includes competence; this would include our clinicians like CNAs, nurses, therapists, ensuring they achieve role-based skills and knowledge. The second C is confidence, which grows through repetition, consistency, validation, and organizational support. And the third C is a commitment to continuous quality assurance, this being ongoing review, root cause analysis, staff validation, and system checks.
The next step, defining and training on their primary roles in skin and wound care programs, wound prevention, healing, and clinical outcomes, is key. One way to address this is by teaching our CNAs they are primarily preventers. They are the early detectors. They are providing the daily care. They know the residents better than anyone in the facility, and their ability to communicate timely and consistently will lead to a better, successful program. We can look at the nurse as a predictor. They are the ones who are consistently doing risk identification through various assessments. They're developing a plan of care, and they are responsible for a consistent reassessment. We can then add the therapist who we could call the promoter. They primarily are focused on making sure the resident is as mobile as they can be. They will provide modalities at the point that it will impact wound healing or just general overall well-being. They can also provide education to our staff and our residents and their loved ones or caregivers.
As I mentioned earlier, aptitude, attitude, and application are the variables that exist in each of our clinicians. This is key in who is best to lead your wound and skin program, who is going to be barriers to success, and who can be salvaged through the three Cs process to solidify your program foundation. Simply put, a key takeaway is we should focus on their skill level, their mindset, and accountability. They are building a successful program through their commitment.
We can't forget that a one-and-done mindset with building successful systems of any kind will lead to huge gaps and ultimate failures. So our fourth C is developing consistency, whether that is the clinician themselves or administrators stabilizing goals, resources, and expectations.
And lastly, because we can burn out quickly and oftentimes become deflated and defeated in wound care outcomes, we should foster creativity for all of our stakeholders and clinicians to engage in wound healing practices, reward systems, and certainly, celebrating successes.
There are some basic strategies we can adopt that set us on the path to success. Skin care strategies supporting skin and wound care management and outcomes include teaching principles of skin integrity. The more our staff and caregivers understand about the skin, the better stewards they can be. We want to spend time teaching what intact or at-risk or wounded skin looks like and how it reacts to different environmental stresses as well as best practice treatments. Speaking of that, we want to use evidence-based interventions. This could be how we cleanse a wound, how we address moisture or manage the periwound, Certainly, addressing infection prevention or infection treatment, doing the least amount of dressing changes, using advanced modalities when it's appropriate or a wound is stalled, like e-stim or negative pressure, providing continent care and good skin care. We should also train our teams to identify and deliver on preventative strategies. Each resident would need an individualized repositioning plan, different types of offloading, use of support surfaces, mobility training, certainly hydration and nutrition, very important to address psychological and emotional support, teaching our residents or patients to do self-care, and training their caregivers.
We can also integrate the iCARE Model in training, which ensures timely documentation and care in a comprehensive way. iCARE is a very simple and concise way to drive compliance and action by our clinicians. We don't have to overcomplicate workflows and processes to get great outcomes.
iCARE is an acronym. i stands for information technology. We all work with various EMR platforms. One of the opportunities that we have is to maximize the sophistication of that platform that can design evaluations and assessments to minimize the number of required questions based on different characteristics of what we're documenting. It can also help prevent documentation that might not align with what we are seeing. For example, oftentimes we have a stage 3 and we end up calling it a stage 2, but we have granulation tissue. There are ways to build assessments with sophistication to know the difference and help our clinicians know the difference and improve the quality of our documentation and the outcome. C is for capture quickly. When we admit a resident in post-acute care, many times our residents or patients are coming with prior skin damage. Our ability to inspect the skin within the first 3 to 4 hours is very key to differentiate us ending up owning that particular skin or wound issue. This is very important in the long run for quality measures and other ways that were looked at based on acquiring rates. It certainly also gives you an opportunity to put in good interventions and understand what type of additional services need to be care planned in spite of waiting within that 24 hours. A is assess accurately. We just want to make sure that we have the right etiology. We have the right type of treatment that matches the wound, the right types of preventative equipment that matches their risk score, and so on. R is for refer appropriately. We know that wound healing and wound programs and wound treatment is an interdisciplinary process. So that means we're involving our dietitians, our therapists, our activity social workers, all of those individuals, psych, getting our wound physicians or primary medical professionals involved right at the very beginning to develop the best plan of care for our residents at risk or with current wounds. And finally is evaluate frequently. It's not a one-and-done. We certainly need to be evaluating and re-evaluating as our residents' conditions change, improve, or decline so that we can timely change our treatment plan.
As we move into individualizing care and care planning, there's a natural progression and workflow that integrates all of the concepts introduced so far. We know that our approach has to be patient-centered, and there are many considerations as we develop the best plan of care. Very important is all of the conditions that the resident's body is battling. We need to address the listed comorbidities and their potential impact on the body's ability to maintain a healthy skin organ or may contribute to the decline of skin or interfere with wound healing at all. We also need to address whether or not immobility is going to be a hindrance; necessarily involve the right clinicians to get that going. We have to look at their skin type, their skin tone, and their fragility. We know that as we age, our skin changes. It becomes less elastic. It comes at greater risk. It's less hydrated. And so we need to make sure we're addressing how our residents go about their day, how their skin is cared for, how it's protected. And we certainly need to make sure we understand historical wounds, because we may have healed a stage 3 in the past, but that same area is not going to be the same ever again. So there's going to be an extra level of risk for that wound to reopen. So the patient's plan of care needs to address that and what we might do proactively to prevent it from breaking down.
We've talked about psychosocial, and adherence factors are probably one of the greatest barriers to wound healing or compliance because our residents are complex. No one probably wants to be in a post-acute care setting. They may be battling depression, failure to thrive, have some kind of psychological condition, all the stressors in the world, and we have to address those. We can't just say the resident refuses, the resident refuses. We really need to dive in and see if there are professionals that can assist them, if there's a treatment regimen, non-pharmacological or pharmacological, that could assist them in being more compliant.
And then, as we've discussed, interdisciplinary collaboration has to continue. This is where, most importantly, the nurse primary role of predictor, the CNA primary role of preventer, and the therapist's primary role of promoter come to life.
And then we can’t ignore operationalizing success. So we can't expect our clinicians to be batting a thousand if in leadership roles we're pulling the rug out from under them and creating gaps or changes or too frequent changes, whether that's in products or expectations for workloads or abandoning orientation. That is, in itself, going to create failure for our clinicians who've made that commitment to care for our residents and patients. With that said, standardizing products and formularies to reduce variability can be very strategic and helpful to not undermine our clinicians.
Let's briefly look at a case study. We'll meet Mrs. Lillian R. This is a typical post-acute care, certainly a typical SNF resident, maybe even a home health resident. She's 82. She is in a SNF. Her Braden score indicates that she's at high risk. Her BIMS is 7. She has significant cognitive deficits. Her comorbidities are many. She has diabetes; it's poorly controlled. She has PVD. She has stage 3 chronic kidney disease, congestive heart failure, throw in Alzheimer's and dementia. Oh, by the way, she has a lot of arthritis and can't get around really well. She also has recurrent UTIs, and she had a reopen stage 3 sacral wound with a history of moisture-associated skin damage. Her functional status, she needs assistance with ADLs, incontinent of urine, wheelchair bound and requires repositioning help.
She has a pressure injury, as we said, a stage 3. You see the, it's on the sacrum, the size. You see it has undermining, which we know that could be because of shearing forces, how she's moved up and down in the bed. Moderate, serosanguinous drainage. The surrounding skin is fragile, and it is not happy. So, we also have a diabetic foot ulcer. It's on the plantar surface, the right foot. It has a dry base with slough. The drainage is very minimal, and the surrounding skin has callous edges. Her MASD is currently managed very well with good skin care and continent care.
The interdisciplinary treatment plan would begin with the medical provider, primarily coordinated with nursing. The CHF management is going to be a priority to optimize, which will require adjustment in diuretics. The asterisk there is we need her to remain hydrated to optimize wound healing and also prevent deterioration of her skin elsewhere. So we kind of have a push-pull scenario. We can’t be tunnel-visioned and only treat CHF. We need to know that our treatment plan may affect other conditions that the resident has. We need to obviously have strict glycemic control, with insulin titration, but we need her to eat. And many times with residents with dementia or Alzheimer's, or frail, they only want to eat sweets. And in the theater of wound healing, calories is calories. And that's our goal is maxing calories. Therefore, we really need to stay on top of the glycemic control with insulin to allow her to consume whatever she's willing to consume.
Of course, pain management right now is PRN. However, we need to consider, with the mild Alzheimer's, she may not be effectively communicating when she's in pain. So there probably needs to be an assumption that there is pain and schedule the pain management, and then certainly before wound care.
The wound care nurse obviously is going to be treating the wound. A basic treatment plan is cleansing the wound, applying a foam dressing. We know that the border, the resident surrounding skin is frail, damaged, so a good skin prep so that that dressing will stay will be important. Considering negative pressure therapy, if no progress. But also due to the confusion and pain, the goal would be the fewest dressing changes possible. In general, the fewest dressing changes possible is good for wound healing, creating that environment, stabilizing that environment. But also when our residents are going to undergo pain, it's just a chore for them, we really want to weigh out the benefit of daily QO, you know, QO day or Q3 days versus Q7 if we can do that so that we reduce the amount of times we have to do dressing changes.
As far as the diabetic foot ulcer, the debridement, if indicated, which because there were callous edges, there was slough. It's generally recommended that it be debrided. But do we want to do that autolytically? Do we want to do that in a sharps format? What is going to be the most important thing that will not create unnecessary pain and discomfort for our resident? And knowing they're not standing on that foot, is it really a priority? So that would be a good discussion with the IDT team to make that determination. And then certainly whether or not diabetic shoe or boot for offloading is needed.
So we'll move on to interventions. Basically, the right treatment at the right time, at the right frequency is always the right plan of care. Cleansing, wound bed prep, infection identification, primary and secondary dressings, securing the dressing, and then as we talked about, decreasing the number of dressing changes and maximizing patient comfort. We need to also be looking at the specialty support surfaces and mobility. This resident was bed and wheelchair bound. They have the stage 3 sacral ulcer. This person would likely benefit from a therapeutic support surface while in bed, maybe manage their microenvironment climate because of the incontinence. So maybe a low air loss, alternating pressure would be the best fit. And then certainly an aggressive pressure redistribution cushion whenever they're in their wheelchair.
Again, hydration and nutrition has to be addressed. That could be orchestrated with the dietitians, speech OTs, so that we get safe PO intake to aid in wound healing. We would be monitoring albumin, blood sugars, basic metabolism, and other pertinent labs to ensure adequate intake. And then not forgetting that maybe they need feeding assistance and/or adaptive equipment just to get the food to their mouth and safely swallowed.
Then, of course, caregiver and patient teaching. If we are educating caregivers, we're ensuring their ability to participate in their plan of care and get proper monitoring, repositioning, ongoing support for wound healing, and it addresses noncompliance, refusals, comorbidity impact, and transparency for goal setting.
So monitoring and documentation of this resident, we obviously know that we cannot have tunnel vision. She doesn't just have a pressure injury on her sacram. She has many comorbidities. We need to document the progression of those so that we can continue to work our priorities as they will impact wound healing. Managing which worsens first and what is best for the patient should be discussed up front as possible outcome scenarios so that care planning decisions are made when the patient is most stable and the family is less stressed. We typically do not do a very good job of projecting into the future based on what we know the resident has. And that first care plan conference is really, really critical to go through the list of all of their active diagnoses and get to the level of understanding how that diagnosis impacts the potential to develop skin issues, to interfere with wound healing, or maybe never heal a wound. If they learn this information up front, the patient and the caregivers, when things maybe go south, without our control, the body just deteriorates or these conditions exacerbate. They understand it wasn't something we did or didn't do. They know that it's just based on life choices, genetics, other conditions that combine to put the resident in this scenario. So focus on when they're less stressed to provide education and re-educate so that we have plans in place for when things do start deteriorating. And that includes talking about if your mother or father or whoever gets to a certain point, these are some of your options: palliative care, hospice, just keeping wounds clean and dry, free of infection versus very aggressive types of services. And certainly document compliance or lack of. It's very important that it exists in the medical record, timely, but it also needs to reflect what the facility's interventions or attempts are to get them compliant.
And then finally, routine assessments, updated risk scoring, because the care plan has to be dynamic. Our residents change every day. They may acquire a new diagnosis. They may exacerbate 2 or 3 comorbidities, and then you have a non-healing wound on your hands. So you have to be looking at the changes in your residents on a consistent basis, sometimes it may be more than what's the general required. You have to base that on how critical your resident is or how unstable they are. And then just communicate, communicate, and communicate. The greater transparency, the better for the patient, because there can be a clear care plan and path based on multiple possible outcomes for the resident. And it shows that the interdisciplinary team, the physician, the family, and the resident are all informed and prepared.
As we move into patient education and communication for successful skin and wound care outcomes, we need to empower the patient, resident, and/or family members with skills that they can become their own self-promoters. If motivation or behaviors interfere with ideal wound care and interventions, we must address this through resources like psych, med management, socialization, educating them, repeated education, and demonstration. So some of the things we could address for self-care are dressing changes, bathing tips, symptom recognition for if a wound might be becoming infected, doing self-inspection, how they can advocate for their own hydration and nutrition, how they should be using their pressure redistribution devices. And then what their habits and comorbidities will impact on their ability to avoid developing wounds or be able to heal wounds. We should empower patients and caregivers to monitor themselves by teaching the simple identification and management tools.
For motivation and behavioral strategies, goal setting with realistic healing timelines or developing palliative care based on pain-free and infection-free strategies for wounds that are not expected to heal is important. Compassionate approach to non-adherence—identify a team member they trust. Offer psych or counseling services. Provide repeated education through various formats. They may not respond to verbal, but maybe they like to watch YouTube videos. Maybe they need a visual demonstration or in written form. And then encourage the patient to have ownership of daily practices, empower the patient because many times they have little control of anything else.
Another important strategy is to expand the wound healing team. Many of us will lose direct oversight of a patient resident's wound outcomes by them moving through the post-acute settings to next level of care. We generate carryover and success by expanding the team to resident family or other support systems available that benefit all of post-acute care and patient outcomes. So if we're going to look at involving caregivers, we will coordinate across disciplines and identify how the patient wants family involved, discuss frequency of notifications desired, and identify caregivers who are willing to be taught. I'll tell you this is a really important step. Not everyone wants everyone to know their business, but if there is someone they would like to remain informed, we need to make sure that happens. And we need to make sure it happens in the format, delivery, and frequency that they want that to happen. We should teach observation and reporting skills like CNAs and family can recognize changes early. They are the first line of defense, and they know the patient best. We should support caregivers, including your staff and the patient's family to prevent burnout. This is not a sprint. It is a marathon. And many times these residents are complicated, maybe develop failure to thrive, deteriorate rapidly. And it's not just difficult for the resident. It's difficult for anyone who's providing care or loves that resident.
So if we forget everything we talked about today, the SUCCESS framework is an excellent unifying model to bring it all together. SUCCESS is an acronym for S, secure staff competence and confidence, education, orientation, validation. So back to the three Cs. Utilize interdisciplinary roles for optimal skin and wound care outcomes, so our predictor, preventer, and promoter roles, CNAs, nurses, therapists. C, consistency in protocols and product use, reducing change, leading to undermining your team members, so that is our corporate commitment to consistency. C, communication with patients, caregivers, and IDT that is transparent and proactive and creates realistic goals. E, evaluate progress, gaps in best practices, and barriers frequently to produce cycles of improvement. S, sustain quality through leadership, quality assurance, and staff engagement. And finally, S, share your team's patients’ and facility successes in skin and wound care.
Summary and key takeaways: the skin integrity is dynamic. Prevention, protection, and healing must be proactive. Clinical team must be competent, confident, and committed to consistent quality assurance. Individualized care is essential. Tailor plans based on comorbidities, fragility, and realistic and compassionate goals. Education and communication drive long-term success. Engage patients, families, and staff at all levels through transparency and excellent documentation. Frameworks like iCARE, 3Cs, and SUCCESS provide structure and consistency in achieving wound care outcomes, creating a system of gap analysis and cycle of improvement.
Dr. Jeannine Maguire: Thank you, everybody. On the behalf of PAWSIC, I want to say thank you to WoundCon. Thank you to Halyard. And, of course, thank you to our expert and speaker, Tara Roberts. So we have some time now. Let's go ahead and post some questions to you, Tara.
Tara Roberts: All right. Sounds great.
Jeannine Maguire: Great. So the first question we have here is: How important is your, when you have turnover—so we all know turnover is a major issue for all of us in post-acute care and skilled nursing—when you experience that turnover, what does that do in terms of your success for your skin and wound care program? And how would you recommend we handle that in the field?
Tara Roberts: That's an excellent question. We know that turnover creates going back to the beginning, a start over. Not only is it costly, but it also costs us the ability to progress in our skin and wound care programs and their consistencies and their outcomes. Many times, if you're lucky enough to have a treatment nurse, there's two things that can happen. You could hire the wrong person for the role, which will be disastrous. So we can't be a warm body gets to be treatment nurse. Or we get the right person and we've not committed to the structural support for that individual to succeed to run one of the most important programs with your director of nurses in post-acute care. So we all know we have, you know, fires that happen, complaint surveys, unhappy residents, staff illnesses, or just we're constantly rehiring in all of our positions. That leads itself to pulling those key people and those very important roles to do roles they’re qualified to do, but it takes them away from what they were hired to do. Most people are good with that if it's occasional and they're supported as they provide support in other areas to make sure that what they're responsible for still gets done. But if that is a consistent way that your system is run and the person is never given the space and breath and time to do what they were hired to do, they're not going to stay. So be honest with yourself about when you look for the person for the role. Are they right? And can you support them to make sure that your program succeeds? And then when that time or that tenure of that individual continues, they're not only going to grow in your facility. They're going to grow in their role. They're going to grow in future knowledge, become a wonderful train the trainer, build that depth for your staff. And, you know, you can only succeed in that way.
Dr. Jeannine Maguire: Mm-hmm. I love that. And it reminds me of, in my previous world in post-acute care, my chief nurse officer at that time, Nancy Grimes, would call what you said, pulling people in who don't have training and you're now doing skin/wound. She would call that the “poof” method. Poof, you're the skin lead now.
Tara Roberts: <laughs> Yes.
Dr. Jeannine Maguire: And she said the poof method was never successful, and yet we still will continue to wash and repeat that. So what I'm hearing you is honesty about what's going on in the facility and about what this position needs, support, recognizing that none of us, nurses, PTs, physicians, have the education or competency in school when it comes to skin/wound. So we need an effective support system and a train the trainer. And then the last thing you said was make sure it's the right person in that role.
Tara Roberts: Absolutely.
Dr. Jeannine Maguire: So they can grow.
Tara Roberts: That's awesome.
Dr. Jeannine Maguire: Thank you for that. Okay. All right. So the next question is, so we see in wound management, we have mobile wound groups, wound care groups, and so on, that come to the facility and provide support with wound rounds for more challenging patients. How does this help a program? How does it challenge and maybe not always help a successful prevention and treatment program?
Tara Roberts: Also a good question. And something over my 30 years I've gone back and forth with seeing the value and also seeing the challenges that they bring. The biggest thing when you explore adding external sources or outsourcing skin and wound care is we can't forget at the end of the day, whatever setting, you are responsible for the resident, their assessment, their progress or lack of progress, what survey sees, and so on. So whoever you're bringing in needs to be cognizant that they're supporting your team to grow in their knowledge, to be consistent so that they can be consistent in being able to deliver services when they're not around. We’re with the patient 7 days a week, 24 hours a day; they see them maybe once a week. And we tend to diminish our role or even give our responsibility over when we invite these outsource groups, when we bring in wound physicians, NPs, PAs, whoever they may be. So being honest with yourself that if you're going to invite this type of support, you cannot reduce the accountability at the facility level for your team's knowledge base, their performance, their ability to respond immediately to changes in your residents, and making decisions on the spot versus waiting for the, quote, “expert.” Of course, the benefit is we know that the wound specialists bring huge value as far as knowledge, expertise, the ability to do bedside services that prevent our residents to have to be transported to an appointment or, God forbid, need to go to the hospital unnecessarily, or have an outpatient procedure scheduled. The efficiencies, the quality of life around not having to leave where they're at, is huge to have those services done bedside. And certainly, there is this perception that surveyors certainly may trust a facility or even our stakeholders, residents, referral sources might trust a facility a little more, knowing they have access to these professionals. And, you don't always have to fully outsource. You could just spend time growing specialists within your organization, and you and I have talked about the use of telehealth just to expand access to those specialists in your organization. But either way, from our LPNs, LVNs, RNs, PTs, they all need to be invested in to maintain their knowledge, ownership of skin and wound care. Because at the end of the day, we're the ones that surveyors, families, residents are going to be looking at.
Dr. Jeannine Maguire: Yeah, 100%. That's such a great answer. And two things. First, shout out to the PAWSIC wound provider checklist. So for the administrators, the DONs, the staff on this call today in post-acute care, use that checklist to vet your external consultant to make sure they're prepared to serve you and your population. The second thing, if I can do math—maybe, maybe not—there's 168 hours in a week. That provider, that expert, is there 1 to 2 of those. So we are, to Tara's comment here, we are responsible for that resident, that patient, 166 hours of that week. So we can't wash our hands of this program. We own it, right?
Tara Roberts: Absolutely.
Dr. Jeannine Maguire: So then, thank you. Okay, this is a question from the latest chat here. Do you have suggestions—Oh, I love this—Do you have suggestions for rewards for staff that do a great job with their skin assessments, their risk assessments, their wound evaluations, their treatments, and just general day-to-day skin care and reporting? And if you don't have rewards do you have motivating strategies perhaps?
Tara Roberts: Okay, gosh, the questions are just great. Very important, and this could be a whole presentation by itself. One, we do need to recognize and that could just be as simple as CNAs consistently reporting changes in skin, changes in condition, timely. And part of that process is nurses, therapists, being receptive to those individuals when they bring that information so that they want to continue to bring that information. So that interaction is really, really critical. But it not only being received well, you can also offer immediate praise right back. So it doesn't always have to be a big production or here's a candy bar or whatever. We respond to positive affirmation, and from our peers is definitely one of the best ways to get it. And it reinforces what they just took the time to do, and realizing their knowledge is going to be the difference between the resident’s outcome when it comes to skin and wound care. There’s other ways to build into maybe your hiring strategies or retention strategies is by building in levels for your CNAs and your nurses. This is something we use. And for each of the levels, they have certain criteria of education and skills they have to ascertain. And when they do, that may come along with, “I've achieved a level 1” on their name badge. It might come with a small increase in their—small, large, whatever you're comfortable doing— in their hourly rate. And then they become recognized for a leader or an expert in those areas that you've created for leveling up. And so that's a great program. So is the affirmation if you're consistent. You can't just every now and then decide to tell someone they're doing a good job or every now and then push for levels, it needs to be part of your framework, part of your culture, part of what you're committed to so that these individuals feel valued. They'll continue to do what's best for the resident and the outcomes will be in the proof.
Dr. Jeannine Maguire: I love that. So I'm going to reiterate some of that, and you can just correct anything I have wrong. Some of this sort of reiterates what you've already said. It's important that before you even think about the different ways to acknowledge people or to reward them, you have to make sure the system is set up for their success. You have to have the right people ini the right role and the education, understanding that they are unlikely to have had it at the expectation we need for success in post-acute care. So that's sort of the table stakes of this. Would you agree with that?
Tara Roberts: Yes, because we need to not assume they just didn't want to act on what they found. We need to assume they may not have ever been educated, which I kind of feel like is where you were headed a little bit.
Dr. Jeannine Maguire: Yeah.
Tara Roberts: So that if we've not done that work, then we can't expect people to advocate on the behalf of a resident, in particular their skin and wound health. So, and then certainly behaviorally, we all need to be receptive when someone takes the time, effort to tell us something about a resident.
Dr. Jeannine Maguire: Yes, 100%. And then on the other side of that, you said first, you have to be consistent in what and when and how you acknowledge. So making sure that your leaders in your center have that consistent response to behaviors that you want to become habits. So that consistency is key. And then you also said that you have levels for your, I assume you mean your nursing assistants or is that accurate?
Tara Roberts: Yeah. So a CNA level program and then LPN, LVN, RN level program, so.
Dr. Jeannine Maguire: Okay. And then what about consistency in when the fair minimum is not occurring? How do you ensure that that is the habit of a facility that we acknowledge the above and beyond and the behaviors we want, but we also need to make sure that we consistently acknowledge the behaviors we don't want.
Tara Roberts: Well, and I think that's a challenge because we don't have a massive pool of staff to hire…
Dr. Jeanning Maguire: Yes.
Tara Roberts: …to replace those who have apathy about their job, right? So we're probably going to have to spend a little more time than we would like working with those individuals and again the first thing is to not assume they knew, so repeat the education, orientation, check clinical skills, whatever it is. Make sure that they are, what their learning style is. I don't learn auditory, I'm a visual learner, and we have so many different ways to shoot information out at our team members. We need to make sure that it's digestible, so little chunks. It's the way they may want to receive the information, a text, a YouTube, private link, whatever that looks like. But you won't know those things until you learn your staff.
Dr. Jeannine Maguire: Yep.
Tara Roberts: Get their feedback. What motivates them, what doesn't motivate them, how do they feel like they could receive information, consume it and use it? We all know we don't have an hour to sit down and do a training. It just doesn't exist. So do your homework so that all those folks who may be “underperforming,” and I put that in quotes, because we don't know why they're underperforming, so that you can give them an opportunity to get on board or find another seat on the bus, which we say a lot.
Dr. Jeannine Maguire: Tara, did you want to elaborate on anything else you were saying about the observations to identify maybe habits that are not optimal, identify opportunity to improve, to behaviors we want to see for skin success?
Tara Roberts: Yes, absolutely. Basically, we're just saying that we can't just deliver the education and then not observe the performance of what they learned. And this isn't a punitive activity. It should be a confidence-building activity. And I was bringing up the examples of if we never go in with our treatment nurse while they're doing a dressing change, they may have picked up an activity that is not going to be infection-control compliant. Well, survey is going to find that when they pop in. CNA is doing pericare. I mean, all of those things need to be observed. And how we approach that observation will make the difference between the employee feeling like they're being disciplined or they're being built up. And so it needs to be out the gate that our goal is to not only train you in the skill, but we want to make sure you get so comfortable with the skill, you wouldn't care who was watching you.
Dr. Jeannine Maguire: Yes.
Tara Roberts: And so they also understand it's just not, it's not punitive and a wonderful teaching opportunity.
Dr. Jeannine Maguire: I love that. I love how you worded that. And I visited hundreds of facilities in my career and have seen and learned so much at bedside, going in early, doing rounds with the CNA, hanging out with them when they're doing the morning ADLs. And two things come to mind that was just so telling. Because, as you said, it's not just the person. It's the education and the system they're in. And I recall one story where I was in at 6 or 7 AM to observe the CNAs. There was nothing punitive. I just wanted to learn. And what I learned was this CNA was going to the pharmacy or their Walmart or whatever in the mornings and buying all these different products for the patient because central supply didn't have it for them. And she was doing the best she could for the residents that she truly loved.
Tara Roberts: Yep.
Dr. Jeannine Maguire: And so, unfortunately, it was causing some skin issues. But my goodness, didn't I learn so much about the system and the support that was so lacking in that facility? And this amazing CNA who might have been, had some issue because they felt that the care issues were related to her, which clearly she is somebody that is a rising star, not somebody that should have been, had a punitive issue. The second one, I recall was a group of, this was a PA center and the CNAs were using a petroleum base, petrolatum base, which is fine. They were using it for prevention. Maybe it's fine. Maybe it's not fine. I don't know. But what she was doing was after she would put it on the patient's skin, all the leftover on her glove, she would wipe on the brief, essentially sealing the brief shut. So the brief couldn't absorb any of the incontinence. And so clearly that was why they were having this big issue with IAD in their center. Again, that was just an easy little tweak in behavior that was an education issue. So, when you hear all that, can you reflect to me anything that you've learned with your staff doing rounds with your CNAs or even the benefit of bringing a CNA to wound rounds?
Tara Roberts: Well, and that is huge because we have to get out of the ivory tower…
Dr. Jeannine Maguire: Yes.
Tara Roberts: …and we have to stop assuming we know what the challenge is. It's not rocket science. Well, yes, it is, because we have humans taking care of humans, and every human we take care of is different. And so I love what you said, when you're saying, “Hey, I'm coming in because I want to learn. I want to learn how you're doing things, what we've set you up, what we've care planned for you to do. But is it really working for this resident and you, not just the resident?” So really, that's the biggest piece. And the CNA is the most reliable person to tell you everything you need to know about your resident. They spend the most time with them. They know what you're about to go in there is going to fail right out the gate, so better change your approach. And they're just ultimately the most valuable team member on the team.
Dr. Jeannine Maguire: 100%. I wish I was live so you could see me cheering for your words right now because that's so true. All right. We're going to end with this last question: Why is a proactive and accurate successful skin and wound care program important for a 5-star quality measure? How does it impact that?
Tara Roberts: So, we all are measured in some way, and we have these systems that either CMS has set up or federally set up that, quote, “measure our ability to take care of people.” They're not always in our best interest they don't always really tell the real picture or accurate picture, but they’re things we have to face and deal with. If you cannot have a skin and wound care program that's firing and that goes back to what we started with—having no turnover, having confident and competent staff, reducing variables, being able to adapt to a resident's individualized needs—we're never going to succeed in those areas of measurement. And when we have, I think it's absurd to think in post-acute care that someone with chronic multiple complexities is coming in with a wound they've had for a year already that we're going to magically heal it. It sets us up for expectations that we can't live up to. What we can live up to is doing what's right by the patient, by the wound, being consistent, advocating, all the things. So quality measures might not always tell the story, so you need to know your story. So if you know your gaps, your successes, how you've improved things, how you've invested in your team, their knowledge, and built those relationships with your residents and families, quality measures will matter “less,” but it's still something we have to pay attention to. So we don't want to grow wounds if we can avoid growing wounds. We want to heal wounds as quickly as possible, which means your system, your dressing changes, your interventions, your IDT member consultations, all of that's going as well as it can to make sure this person has a chance to heal a wound or not grow a wound. So you can't ignore it, but if you know your story, you can get past where the quality measure falls short.
Dr. Jeannine Maguire: That's great. Thank you. And I heard so many common themes in all of your responses. I feel like we could go another hour with Q &A, but I thank you for sharing your wisdom on behalf of PAWSIC, on behalf of WoundCon, thank you so much to our sponsor, Halyard, for this opportunity to bring your expertise to our audience. And I think that's a wrap. Thank you, everybody, for your time today.
Tara Roberts: Thank you.