by Raghu Kolluri, MD, RVT, FSVM
I took a position at OhioHealth, a large not-for-profit health care system based in Columbus, Oh in 2013, and was tasked with creating a vein center within a wound center at OhioHealth Riverside Methodist Hospital, a 1,065-bed tertiary care hospital.
For the preceding eight years, I had become accustomed to practicing in an outpatient vein clinic and treating patients with lower extremity wounds in a hospital wound center. I was unsure about the new assignment, but thought it would be an interesting challenge.
The Marriage: How it Works
Our combined center is called the “Critical Limb Care Center” (CLCC) and is part of the Advanced Heart and Vascular Center at Riverside Methodist, which brings together a multi-disciplinary team of specialists to provide coordinated and innovative care to patients in one location.
The structure of the CLCC, and coordination with other specialties, is why our combined outpatient clinic and wound care center has been a success. We collaborate with our podiatry and foot and ankle surgery colleagues in this center to deliver comprehensive wound care and hyperbaric oxygen therapy. We have a vascular nurse practitioner who evaluates all new patients referred to the CLCC for underlying vascular issues, both arterial and venous. With this set up, identification and diagnosis of peripheral arterial disease (PAD), venous reflux and iliac vein obstruction becomes a seamless process.
On several occasions patients may undergo a cath lab intervention for iliac obstruction while they are receiving wound care for venous leg ulcers (VLUs) arising from post-thrombotic syndrome and, eventually, also undergo superficial endovenous procedures to decrease the venous hypertension—all in the same facility. Patients with mixed etiology ulcers also undergo peripheral arterial interventions before initiation of compression therapy.
Keys to a Successful Union
One example that illustrates the benefits of a combined center is the case of a woman in her seventies who was referred for bilateral venous leg ulcers. She was treated at another facility for the past several months and had multiple rounds of Apligrafs. After frustrating trips to that wound center and after trying all types of compression therapies, she decided to seek a second opinion. The day I saw her in the vein clinic she was able to rattle off the differences between Unna boots, profore wraps and compression socks, and had an extensive knowledge of wound care products. I was dealing with a highly-educated and empowered patient.
Upon evaluation, the venous incompetence study showed extensive reflux in the bilateral great saphenous veins and also a pathologic perforator reflux in close proximity to the wound. I shared these results with her and said, “I think I can do better.” She was thrilled and shared that she liked the convenience and close proximity of the clinic, vascular lab and wound clinic, where she could see her podiatrist.
Within weeks she underwent bilateral great saphenous ablation and adjunctive foam sclerotherapy in our vein center, which is housed within the wound center. All along, our podiatry colleague and I monitored her wound care. I can’t think of any other way we could have provided this comprehensive care under one roof, unless the vein clinic is housed within the wound center.
Enhanced patient experience
The clinical advantages of a combined center aside, we knew we’d have to deliver a top-notch patient experience to ensure the center’s success. Vein disease has long been considered a cosmetic issue and most expect to get their veins treated at a spa-like facility. We perform all of our endovenous therapies in the outpatient facility within our CLCC. To counteract any potential perception problems, our administrators paid particular attention to the waiting area and the overall appearance of the CLCC. Our concierge greets every patient with a big smile, whether it is a patient with wounds or without. He assists all customers to numerous areas of our clinic, maintains an average wait time of less than four minutes and helps us achieve Press Ganey scores that are consistently >90 percentile nationally. Hence, a negative perception does not seem to be an issue in our practice.
A well-run vein clinic can be a substantial component of the wound clinic revenues since VLUs are the most common leg ulcers. We noted that billing accounted for approximately 40% of our wound clinic revenue (excluding hyperbaric revenue) within the first fiscal year. And, we have not had any denials of our procedures thanks to good documentation from our billing and coding department.
There certainly may be some additional steps required to perform these procedures in a hospital setting. We must conform to hospital policies for conscious sedation and be ACLS-certified. Any new product undergoes scrutiny through hospital committees. For example, Varithena had to go through the hospital pharmacy and therapeutics committee for approval, which may not be required in an outpatient clinic. Pharmacy also purchases and supplies us with tumescent anesthesia solution and sclerosants for each case. But, I like this process since there is oversight at every step.
Setting competitive cash services for cosmetic therapies could also be a challenge in a not-for-profit setting, but with guidance from the legal counsel and folks from ethics and compliance, it is achievable. The beauty of this setup for the physician is you are able to rely on experts in their own fields to ensure you are legal and compliant. I have a lot of support from people who know their job and do it well, so I can concentrate on being a doctor.
Reflecting on the Partnership
Overall, I find the operation of an outpatient vein clinic within a wound care center an effective way to provide coordinated, comprehensive and advanced venous care to patients. And the patients seem to appreciate the convenience of receiving a broad spectrum of venous evaluation and treatment in one centralized location.