“Organizing a Wound Healing Program: Replicating a Model That Works” Welcome to the IHS Clinical Rounds June 14 th , 2012 Host: Susan Karol, MD; IHS Chief Medical Officer Presenter: John Farris, MD; CMO, IHS Oklahoma Area
Objectives for Today’s Rounds • Define the key factors for developing an organized approach to wound healing within Indian health care. • Differentiate between healing wounds and building an organized wound healing program • Implement processes and strategies for a comprehensive wound healing program.
Accreditation • The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The IHS Clinical Support Center designates this live educational activity for a maximum of 1 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. • The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. • This activity is designated 1.0 contact hours for nurses.
Disclaimer Accreditation applies solely to this educational activity and does not imply approval or endorsement of any commercial product, services or processes by the CSC, IHS, the federal government, or the accrediting bodies.
Guidelines for Receiving Continuing Education Credit • To receive a certificate of continuing education or certificate of attendance, you must attend the educational event in its entirety and successfully complete an on-line evaluation of the seminar within 15 days of the activity. At the end of the evaluation, click on the appropriate line to obtain your certificate, fill in your name and print the certificate. • If you need assistance, please contact Dr. Chris Fore (chris.fore@ ihs.gov) or Mollie Ayala (mollie.ayala@ihs.gov).
Faculty Disclosure Statement • As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of this information will be included in course materials so those participating in the activity may formulate their own judgments regarding the presentations. The course directors/coordinators, planning committee members, and faculty for this activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose.
Topics for Future Rounds July 12, 2012: “The Baby Friendly Hospital Initiative” Suzan Murphy RD MPH; Phoenix Indian Medical Center August 9, 2012: “Standards of Care and Clinical Practice Recommendations: Type 2 Diabetes” Ann Bullock, MD; Cherokee Hospital Sept 13, 2012: “Improving Timing Stroke Care: Advances in Tele -Stroke Consultation” Dr. Bart Demaerschalk; Mayo Clinic
Meet the Presenter Dr. John Farris is the Chief Medical Officer for the Oklahoma City Area Indian Health Service and a member of the Cherokee Nation of Oklahoma. He attended undergraduate schools at the University of Oklahoma in Norman, OK and Baker University in Baldwin City, Kansas, attaining a B.S. in Biology in 1981. He attended medical school at the University of North Dakota, School of Medicine in the INMED Program and completed his medical education at Michigan State University College of Human Medicine, receiving his medical degree in 1985. He completed an Internal Medicine Residency at the University of South Dakota, School of Medicine, in Sioux Falls, South Dakota, and also served as the Chief Resident in Internal Medicine for 1 year. After residency, Dr. Farris worked as a staff physician in the Internal Medicine Department and then was appointed medical director of the Respiratory Therapy Department at the VA Medical Center in Ft. Meade, South Dakota. In February, 1996, he joined the staff at W.W. Hastings Indian Hospital in Tahlequah, Oklahoma as the Director of the Emergency Department and was selected as Clinical Director in November 1996. In August of 2004, he assumed the Chief Medical Officer duties for the Oklahoma City Area.
“Organizing a Wound Healing Program: Replicating a Model That Works” John Farris, MD, Chief Medical Officer Indian Health Service – Oklahoma City Area Indian Health Service Clinical Rounds June 14, 2012
IHS Priorities Dr. Yvette Roubideaux - Indian Health Service Director 1. To renew and strengthen our partnership with tribes 2. In the context of national health reform, to bring reform to IHS 3. To improve the quality of and access to care 4. To make all our work accountable, transparent, fair and inclusive
Objectives: 1. Describe the factors in developing an organized approach to healing wounds for American Indians 2. Highlight the difference between having an organized wound healing program and treating wounds 3. Understand the implementation of a comprehensive program on patient outcomes and satisfaction, the financial impact on the facility, and barriers they will face with implementation
DIABETES In America 120 119.3 • 23.6 million people in 100 the U.S. have 77.7 80 diabetes 60 • ¼ don ’ t know it 40 25.2 • 15% will develop 20 Diabetic Foot Ulcers 0 (DFU) • Death rates are increasing
2011 National Diabetes Fact Sheet 14.2% of American Indians and Alaska Natives aged 20 years or older who received care from IHS have diagnosed diabetes. 16.1% of the total adult population served by IHS has diagnosed diabetes, with rates varying by region from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona. Among Native Americans in Oklahoma the rate of diabetes is 15.2% http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Wounds: a serious health risk predictor for Native Americans… 1. Lee JS, Lu M, Lee VS, Russell D, Bahr C, Lee ET: Lower extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study. Diabetes . 1993:42:876- 82.b
Do diabetes-related wounds and amputations cost more lives than some cancers? YES! Nearly half of all unhealed neuropathic ulcers have other co- morbid states that will result in patient death within 5 years if not resolved ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 4 No 4 strong 2007;4(4):286-287.
Disparity Exists for Indian Health Service Patients • • Wound patients have a There is no mechanism for higher level of co-morbid continuity of care conditions • Clinic structure is not • Education on risk factors designed to merge the and Peripheral Arterial needs of patients with Disease is insufficient wounds that require extra time and special interventions • Amputations are viewed by many providers as definitive • care for even simple There is a consistent wounds practice of utilizing CHS funds for either convenience referrals or • Consultation with specialists emergent/urgent care is not readily available
National Economic Costs Comparisons … $892 1000 800 $671 $ Billion $515 600 400 $227 200 0 Cancer PAD and National HHS Overall DFU/Wounds Defense
Why did we develop a Direct Wound Care Program Increasing expenditures to care for patients with wounds without consistent results Increasing amputations Oklahoma City Area cost for outsourced wounds averaged more than $17,000 - $22,000 for even simple wounds; CHEF cases that began as wounds often exceeding $1 million dollars with devastating patient outcomes (2004 dollars)
Complications of Diabetic Foot Ulcers DFUs that persist more than 4 weeks have a 5-fold greater risk of infection. 1 Development of an infection in a foot ulcer increases the risk for hospitalization 55.7 times and the risk for amputation 155 times . 1 “Infected neuropathic ulcerations are the leading cause of diabetes -related partial foot amputations at the Phoenix Indian Medical Center.” 2 Foot ulceration is a significant risk factor for lower-extremity amputation in Native American Indians. 3 Diabetes Neuropathy Foot Ulcer Infection Amputation 1. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care . 2006;29:1288-93. 2. Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr Med Assoc . 1989;79:447-50. 3. Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care . 1996;19:704-9. 19
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