Skilled Nursing Facility/Plastic Surgery Interdisciplinary Team Approach: Utilizing Inter-Professional Collaboration and Innovative Telemedicine Technologies to Provide Comprehensive Wound Care Across the Healthcare Continuum

Abstract

Background: A Tertiary Care Hospital along with Skilled Nursing Facilities both locally and distant provide comprehensive care for local and rural patient populations. This system of care is challenged to provide comprehensive interdisciplinary wound and pressure ulcer care across the healthcare continuum including the skilled nursing facility, home, outpatient clinics, inpatient hospital bedside and operating room. Objective/Aim: A system of care was needed to provide comprehensive collaborative care accross the healthcare continuum for patients with complex wounds and pressure ulcers in settings that include the hospital, skilled nursing facilities, outpatient clinics and the home. Quality Improvement Methods: An interdisciplinary team was formed from various specialties including Primary Care, Geriatrics, Rehabilitation, Plastic and Reconstructive Surgery, Complex Wound Care, Nutrition, Psychology, SocialWork, Physical Therapy, Nursing, Telemedicine and Education. This team collaborates across the healthcare continuum to provide complex wound and pressure ulcer management. The SCAN (Specialty Care Access Network) Program is a grand rounds style teleconference linking remote sites and centers to the interdisciplinary team, providing continuing medical education credit for participants and access to specialty wound care for remote patients unable or unwilling to present to themain hospital or skilled nursing facility for care. Telehealth technologies enable real-time remote wound assessment and treatment. Telehealth is used for consultation, follow-up, pre-op, discharge planning, post-op and education. Weekly inpatient interdisciplinary skilled nursing facility rounds involve multi-specialty team collaboration at the bedside. Comprehensive plastic and reconstructive surgery for complex wounds and pressure ulcers is provided by the main hospital. Peri-operative specialty care is provided by the skilled nursing facility. Results: The interdisciplinary team approach focuses onprevention and early intervention for wounds and pressure ulcers and results in improved access to specialty wound care, reduction in bed days of admission, decreased time to operative wound reconstruction, improved healthcare outcomes and quality, and improved patient and provider satisfaction. Complexwound care knowledge is transferred to patients, caretakers, families and providers. Conclusion: Effective evaluation and treatment of skilled nursing facility patients with complex wounds and pressure ulcers is accomplished with collaboration of an interdisciplinary team that addresses prevention of wounds and early intervention across the continuum of care. Author Disclosures: All authors have stated there are nofinancial disclosures to be made that are pertinent to this abstract.