Why We Need Mobile Wound Care

TWC: What is your professional background?
 
Haresh S. Kane, MD, CWSP, Founder and Chief Executive Officer, Kane Wound Care: My background is Internal Medicine. I started my Internal Medicine residency back in 2003 at Jersey Shore University Medical Center. I graduated in 2006 and then went on to jump headfirst and feetfirst into wound care in 2006, and I've been doing it ever since. I'm a Diplomate of the American Board of Internal Medicine, originally certified in 2009. I re-certified again in 2019. I am also a Diplomate of the American Board of Wound Management, where I still maintain that designation.

Michael E. Jensen, MD, CWSP, Chief Medical Officer, Kane Wound Care: I come from a General Surgery background. I was in General Surgery residency in New York City from 2003 to 2008. Right out of residency I had the opportunity to join an up-and-coming wound care group as a Clinical Wound Specialist, providing mobile Wound Care services to Skilled Nursing Facilities in the New Jersey and New York areas. I remained in that role for 12 years until 2020 when I joined Kane Wound Care as their Chief Medical Officer. I am a Diplomate of the American Board of Wound Management.
 
TWC: How did you get interested in wound care?

Dr. Jensen: Historically, wound care was long the purview of the general surgeon and surgical subspecialists. Wound care was a big part of my training in general surgery, long before there were recognized specializations and certifications in the field. Much of my training in residency involved office based wound care and running weekly wound care clinics. During my training, I developed a keen interest in caring for wounds. After residency, the migration into the wound care field seemed very natural to me and has been my passion for the last 15 years.

Dr. Kane: My exposure to wound care during my internal medicine residency was very minimal. To this day, it's not something that's aggressively taught in regular internal medicine programs. Many never had real, robust wound care experience. Wound care is typically relegated to a wound care nurse in hospital systems. I've witnessed that. I recently was asked to evaluate a close family friend who was hospitalized in the ICU of a large University hospital. It was kind of comical to me that none of the doctors or nurses in this medical ICU really had any knowledge of wound care for their patients. They kept telling me to refer to the wound care nurse, and there was only one nurse for this very busy inner-city hospital. This is sadly a situation we see far too common these days.
 
TWC: Why did you decide to start a mobile practice?

Dr. Kane: When I was looking for a job towards the tail end of my residency, I knew internal medicine wasn't exactly for me. The jobs that were offered in those days were either being a hospitalist in a very busy hospital system or joining a primary care practice in the area; none of which were particularly appealing to me. As I scoured the country looking for interesting job prospects, I stumbled upon providing wound care in the post-acute environment in nursing homes, which to me at that time sounded very interesting and very “outside the box.”
 
It was a company based out of Florida and I went down for the interview and shadowed some doctors who were providing wound care in nursing homes. I thought this was the coolest thing I had ever seen in my life, and I wanted to be a part of it, and I could feel myself so energized for the first time in my healthcare career. I was truly excited about doing something in a field that I thought would appeal to me and where I would be very successful. I joined this mobile wound care company in Florida and stayed with them for four years, from the end of my residency until 2010.
 
In 2010, I left that group and went off on my own with this idea that I could provide even better care and do it the way I wanted it to be done, which is the reason why I started Kane Wound Care.
 
My personal vision was always that I wanted to have something of my own and to be able to do it on my own. I wanted to work with people like Dr. Jensen. I sought to build a practice where mutual respect and professionalism were paramount, a collegial type of environment. It wasn't easy when I started off. I was on my own for probably four or five years before I hired our chief nursing officer who's been with us now for nine years.
 
We've really built this beautiful group, Dr. Jensen, me, and the rest of the leadership team. Dr. Jensen was saying the other day that we have so many different people across all walks of life working in our organization. It's something we are incredibly proud of.
 
TWC: How do you connect with facilities?

Dr. Jensen: We have many resources for connecting with facilities, but ultimately a preponderance of our referrals is by word of mouth. There is significant staff movement between buildings, and the SNF “world” tends to be rather small. Typically, if managers or nurses have a positive experience with Kane Wound Care in one facility, they will often seek us out in the next facility they move to. We also have a wonderful marketing team at Kane Wound Care promoting our services. Our education program has also been a significant source of referrals. Often, we will be invited into a facility to provide wound care and ostomy care education to the staff, which leads to them requesting our services. Believe it or not, a lot of facilities are not aware that mobile wound care exists, and this presents an interesting opportunity for us to expand our services.

Dr. Kane: It’s really interesting and exciting to Dr. Jensen and me because we started in the infancy of wound care 17 years ago. I used to go into nursing homes, and they'd look at me and ask me, “Who are you?” And I would say, “I'm the wound care physician.” Their next question almost always would be, “What is a wound care physician?” Then I'd go on to explain that I'm an internist who provides wound care. They would always look at me with this look of wonder. It’s really fascinating to see the changes that have taken place over the past 17 years.
 
You must remember what the landscape looked like in 2006—very different before the Affordable Care Act and other major healthcare changes. It was just a very different landscape, and it has been truly fascinating to see this real kind of evolution in the wound care ecosystem. We always assumed that by now, some 17 years later, there would be a wound care–designated residency program fully accredited by the Accreditation Council for Graduate Medical Education (ACGME) residency that would truly validate the science. Unfortunately, that's still not the case. It’s no different than where ER medicine was maybe 30 to 40 years ago when ER medicine didn't have its own specialty or residency. Lack of specialty recognition and all that that entails is probably one of the biggest challenges we experience as wound care professionals.
 
It ties into so many different things. We pride ourselves on being true wound care professionals and specialists, purists in our field. We are dedicated to the science. We are even obsessed by the science. Dr. Jensen has been known to test the pH of his wounds, just to give you an example of how we are all trying to understand what we can't see. So that's our true kind of hope for wound care. We really hope it's going to turn into something substantial, accredited, and well respected in the field of medicine.
 
TWC: What is the designation of the facilities in which you provide care? How does that affect the services you offer?

Dr. Kane: Typically, your skilled nursing patient is a patient who has been recently discharged from a hospital system, from an acute setting. They may be coming into a facility requiring services such as rehab, PT, OT, speech therapy, and such. They have 100 days of skilled care under Medicare Part A. Many of these nuances are really related to billing. During the first 100 days, most of these services are provided at the nursing home level. After a patient completes their first 100 days of skilled or Part A Medicare, they then transition to long-term care, at which point they require fewer services.
 
For the most part, nursing homes have evolved to become very sophisticated facilities these days—certainly not what we remember them being 20 years ago. We call them SNFs—skilled nursing facilities. Post-acute care (PAC) is another recent term. At Kane Wound Care, we service all skilled nursing facilities as well as several assisted living facilities.
 
TWC: Why do facilities benefit from the help of wound care practitioners?

Dr. Jensen: It’s undeniable, there is a growing need for wound care in the post-acute and long-term care settings. Patients are being hospitalized with greater comorbidities and higher medical acuities greatly predisposing them to the development of wounds. As a result, we are seeing more wounds in the nursing facility setting. Prior to the availability of in-house wound services, patients had to be sent out to wound care centers. This travel involves not insignificant costs, is difficult for patients with limited mobility, and can be disruptive to the patient’s schedule. Many of the patients thrive on having structure in their daily activities, and so sending them out to a wound care center is very unsettling for them. I think that mobile wound care is an important niche in the field.
 
TWC: How do you organize your practice to be efficient?

Dr. Kane: We have 90 team members composed of doctors, nurse practitioners, physician assistants, nurses, medical technicians, transcriptionists, and office staff. Our operations team is really the backbone of this organization. I could rattle off 20–30 people’s names without whose assistance, guidance, and commitment, we would be completely lost. I think it's important to remember that all great organizations have systems and processes in place, and we are no different. It certainly did not happen overnight.
 
I think our true strength lies in our leadership team with our COO, our Director of Clinical Operations, our Director of QAPI, our HR manager, our CFO, our CMO, Dr. Jensen himself, and our Chief Nursing Officer. They really are critical, and we all work together very nicely as a group. We may not see eye to eye all the time on certain things, but we listen to each other and respect each other.
 
Make no mistake about it—when we all meet in our conference room, we playfully dub ourselves the “Knights of the Round Table.” Everyone’s voice is heard and respected. We talk it out and we come up with meaningful solutions and ways to move forward. We're able to move quickly too, because as a private organization, we are not mired by layers of bureaucracy and red tape that other organizations in healthcare are typically haunted by. I see that a lot in other tiers of care, especially on the acute side of healthcare. In the acute setting, it's sometimes difficult for clinicians to make effective change because of the hierarchy structure. You must go through this long chain of command. As private organizations, when we realize there is an issue or a problem, we can deal with it quickly and effectively and come up with the solution.
 
TWC: What are the challenges of working in many different facilities, or in any facility?

Dr. Jensen: I think one of the biggest challenges is that every building has its own culture. It just means that although we standardize our process across all buildings, we work to cater our services based on the requirements and needs of each facility.  This translates into providing additional education services where needed, incorporating wound technologies in facilities with higher acuity wounds or more challenging patients, just as a few examples.

Dr. Kane: We have hundreds of buildings in our portfolio, probably more. When we go to a building, each has its own dynamic and different staffing. It is very much different than a physician or a practitioner working in a wound care center and going into that wound care center five days a week. So that's sometimes the challenge. You are going to so many different places and you must be able to connect with people wherever you are.
 
TWC: What do you find rewarding in your practice?

Dr. Kane: For me honestly, it’s just treating the wounds and healing the wounds. As simplistic as this sounds, one of the main reasons I went into wound care is because I could see things, I could feel it. It was tangible. The changes are tangible versus internal medicine. When I can see a wound contracting or granulating and becoming fully re-epithelialized, it's always a real thrill for me, even after all these years. My second love in this business has been my role as an educator. Dr. Jensen and I both spend a significant amount of time teaching and mentoring the clinicians that join us. I also teach at the Healthcare Association of New Jersey (HCANJ), where I provide education on wound care. I find it extremely gratifying teaching clinicians at conferences and in various nursing homes, whether they are LPNs, RNs, or CNAs. Sometimes I even have physicians poking their heads into the patient's room interested in the wounds and trying to understand the hows and whys of healing. So that is a very gratifying aspect of this business.
 
TWC: What do you find difficult or challenging?

Dr. Kane: The Merit-based Incentive Payment System (MIPS) has been a challenging program for us in wound care, especially because it circles back to this issue of wound care not being recognized as an official specialty. It’s challenging, especially when you're looking at quality measures. It’s unfortunate that we are mandated to report on measures that are not pertinent to our field or scope of practice solely because wound specific measures have not been established. This ultimately comes down to lack of representation in the field.
 
TWC: What is the biggest wound care problem you see clinically in facilities?

Dr. Kane: As exemplified by my recent experience in a very large New York City hospital, the biggest problem is the general lack of wound care education. Senior residents had no comprehension of basic wound care principles or products. It was horrific, to say the least. I was standing in this very sophisticated, technologically advanced ICU, and nobody knew what Dakin's solution was. I think wound care education across the ecosystem of healthcare is extremely poor. And I think we've done a bad job of training clinicians, nurses, and doctors about this beautiful science of wound care. It’s our sincere hope that this will change one day, and I think that the way to bring about this change is by wound care becoming its own designated specialty with residency programs, with its own board, and so on so forth.
 
TWC: Are there any best practice standards that you use?

Dr. Jensen: We have a robust process in place to ensure that we adhere to best practice standards. This process starts at the time of hiring where we put our new providers through a multi-week orientation, customized to their experience level. Our providers round in a facility for wound care once a week, with the additional availability for tele-visit assessments should a new wound present between rounds. Our documentation undergoes a thorough internal auditing process to ensure our documentation is accurate and above board. All our wound providers undergo didactic and in the field training as well as regular performance reviews to ensure they all meet our best practice standards. At Kane Wound Care we want to ensure that we are providing the best wound care possible, obtaining the best outcomes possible.

Dr. Kane: Dr. Jensen and I do go out in the field on a frequent basis. We make the rounds of our facilities to ensure quality care; spot checks if you will. All our practitioners are typically in close communication with us. Being all together in one state makes that very easy, and we encourage that. Consequently, we have a real good pulse on pretty much all our patients and all our practitioners.
 
The training of our doctors and nurse practitioners is top-notch. It's a multi-week, at times a multi-month process—when we hire a provider, even if they may have some wound care knowledge or experience, they still must undergo a rigorous training/orientation program that is supervised. The orienting providers have mentors in the program consisting of more seasoned clinicians. Progress and satisfaction in the orientation process is assessed with weekly check-ins. We get feedback from mentors who are training them, as well as from the orientees themselves. In the post orientation phase, we regularly touch base with our partners in the post-acute world and nursing home world to see how our new providers are doing as well.
 
It's important for us not to just put any practitioner in a particular facility. We like to say, tongue in cheek, that our program is like the Rolex of wound care where we are all about the quality and not the quantity. It’s not a situation where we're just looking for warm bodies—we really do take the time to make sure first we have the right person. Dr. Jensen is very intimately involved with the interview process, and we're both obviously involved with performance reviews throughout the year with our providers, nurse practitioners, doctors, making sure they are meeting our standards, making sure that they're performing to a level that we deem on par with the quality of our program.
 
TWC: Why is mobile wound care such a growing trend?

Dr. Jensen: We touched a little on this in a previous question. Ultimately bringing quality wound care to the patient in their environment where they are comfortable is always a better option. We have a distinct advantage over the brick and mortar setting such as the wound center, as we see the patients in their environment. It affords us the unique perspective of being able to ensure pressure relieving surfaces and offloading processes are in place. We can see first-hand how perhaps a mattress may not be adjusted correctly or optimally for a particular patient. We can assess if offloading boots are placed correctly. We can verify if wheelchair cushions are adequately positioned and inflated. Given the incredible importance of wound prevention and pressure relief in healing wounds, this in-person perspective is an invaluable aspect of the mobile wound care model. Our interactions with facility nurses and CNAs additionally afford us the opportunity to provide significant wound and preventative care education.

Dr. Kane: We can provide any treatment or service that a regular wound care center can provide in this country except for one particular service: hyperbaric oxygen treatment. This is simply because we haven't quite figured out how to bring the hyperbaric oxygen chamber to the patient, in New Jersey anyway. When you look at the services that we provide, we do almost everything. It’s extremely beneficial when a patient does not have to travel to get their care and have the provider travel to the patient. We've seen this model work successfully since the beginning of time. Doctors with their medicine bags going to see their patients and doing their home visits. During the COVID pandemic, Dr. Jensen and I did home visits just like the majority of our providers, making sure our patients were well taken care of during that time, a time when wound care centers were largely closed. So you can see the advantage of mobile wound care and what it provides to society because we were able to bring high quality care to the patient's homes. There are a lot of severe and critical wounds in the home bound patient population as well. Consistent and high quality wound care for homebound patients is another huge need that we see in this country today and the demand is only increasing.