Transcript
Welcome to the SAWC Difference Makers Podcast, where breakthroughs meet the bedside.
I’m your host, Dot Weir. Let’s dive into today’s conversation.
Dot Weir: Well, hey, Cathy, and thanks for joining me today. I have been really looking forward to this podcast because you sort of epitomize the definition of a difference maker.
You and I have had the pleasure of being friends and colleagues for so many years. We won’t even try to count that up. But I have always found you to have such a unique practice. I’m going to let you first introduce yourself and tell people your background, and then I’ll start in with my questions.
Cathy Milne: Okay. Well, thank you. First of all, thank you very much for having me. It’s a real pleasure to be here.
My name is Cathy Milne. I’m an adult nurse practitioner who has a private practice in Connecticut, and we practice across the continuum in acute care, long-term care, assisted living, wound clinic—what did I miss?
Dot Weir: The Burger King dumpster.
Cathy Milne: That’s right.
Dot Weir: That’s amazing. That’s amazing.
That is one of the first questions I want to ask you, because you and I have shared the podium in many, many different types of presentations, and you have such a wealth of knowledge about everything. You really do.
One of the reasons is because you have such a vast practice and practice in so many sites of care. How in the world do you keep up with all of the regulatory issues? We were in a presentation the other night talking about coding and the various places, and you have such a grasp on all the regulatory requirements. You practice in like five sites of care. How in the world do you keep up with that?
Cathy Milne: First of all, I don’t sleep, right? Number one.
But it’s interesting because I subscribe to a lot of different newsletters that alert me to practice changes. Also, just being in that setting, you absorb. It’s like a sponge. People come to you and go, “Oh, did you hear about this new regulation?” You’re going, “No.” And then they tell you their version. Then somebody else tells you a little bit of a different version. And then you start going down the rabbit hole to find out what the real version is.
As you already know, with a lot of these regulations, there are different versions of the same version, even from the government. It depends on which arm of the government you’re looking at. So that’s essentially how I keep up.
I wish I knew all the regulations. But it’s really the regulations that impact people on the ground that I am most concerned about.
Dot Weir: Sure, sure. So you’re going into people’s homes, long-term care—
Cathy Milne: Yep. I made two house calls this morning.
Dot Weir: That is totally amazing. And you have partners?
Cathy Milne: Yeah. There’s another clinical nurse specialist, and then there’s a family nurse practitioner.
We all do kind of different things. One does legal work, and one really manages a huge health system with several smaller health systems underneath. That’s her real job. Her job with Connecticut Clinical Nursing Associates is that she does see patients independently, and her institution allows her to do it.
We started in 1995.
Dot Weir: Wow.
Cathy Milne: Yeah. Way back. And really, it started before that. We had a CNO who was really a visionary and one of my mentors, who basically said, “These people cost us way too much money as an inpatient, so go learn the outpatient piece and keep them out.” And that’s what we did.
Way before mobile became fashionable, we were out there in the nursing homes and home health agencies. We had started a wound clinic, but also a prevention clinic. We looked at people who had diabetes, and we invited them in and did foot screens because nobody else was doing them.
There were quality measures kind of early on, and we would do them and then send them to the primary care doctor, so they would at least have something in the chart and could follow them. She was really a hard person to work for, but a really good person because she saw the future.
Dot Weir: Oh, yes, yes, yes. That’s an interesting statement that you made, that it was before mobile wound care as we know it today, which has had a big hard hit in that industry.
So with where you go, where do you get your supplies? If you do want to place a CAMP or a CTP on someone, how does that all work?
Cathy Milne: It’s really, really difficult in an alternative spot. The nice thing is that because I work across the continuum, it’s actually easier to say, “This is what you’re going to need, and I need you to come into the wound clinic for four weeks before we can do this.”
Do I have four weeks of documentation from another site? Yes. But everybody is so nervous these days that they want four weeks in that setting before you can put on your CTP.
That’s the beauty of going across the continuum, because when you have somebody, let’s say in long-term care, if you want to do a CTP, you have to have all your ducks in a row, and you have to get authorization and so on and so forth. But what I have found, and I got burned a long time ago, is that when you have the CTP delivered to the facility, it gets lost.
Dot Weir: Lost. Oh, it goes to like a receiving department?
Cathy Milne: Yes. Then you’re on the hook for that, and the patient doesn’t get what they need, too.
So in terms of time and effort and what’s right for the patient, it’s actually easier to bring them into the wound clinic and do that.
There are a lot of barriers in this health care system. There’s no perfect health care system; it doesn’t matter where in the world you are. But there are some barriers here that actually prevent us from giving our patients the quality care that they need.
There are patients I could put a skin sub on after a week. I’ve gotten the labs done. Their diagnostics are done. Everyone looks good. It’s been debrided. It’s perfect. But I have to wait three more weeks.
Dot Weir: Right. And that’s a waste of health care dollars.
Cathy Milne: It is.
Dot Weir: Even though you may have been taking care of them in another facility. So just transferring your notes or having the notes and the record—because I absolutely believe that your notes are exquisitely done. Could you get those notes and have them scanned?
Cathy Milne: Yes, and I have them available at the clinic. But it’s the administrators at the clinic who are so scared because they’re interpreting the regulations as four weeks under their billing system.
Dot Weir: Okay. Well, you know what? And it’s true. The way audits are happening these days, why put yourself at risk?
Cathy Milne: Yeah. And clawbacks, does that mean people take back the money? Yep.
Dot Weir: What a stressful thing. And there are patients out there who are in such need, and the need for getting them mobilized to an outpatient clinic just to be able to have the best kind of care when a qualified individual is saying, “This is what you need.”
Well, you’re absolutely right. That is a waste of health care dollars.
I applaud you because, having heard you speak and having heard your patient stories, I know that you go to the nth degree for the folks that you need. I think I’ve met one of your partners, and I’ve shared some legal cases with one of your partners. So you have a very unique and wonderful situation there.
Something else I would like to switch to and have our listeners know about, because this is such a unique benefit that I think not enough people know about and tap into, is that you and Dr. Jay Shah are co-chairs of WoundCon.
Now, WoundCon as a meeting—it’s all virtual, for those of you who are not familiar with WoundCon—is not brand new. It’s been around for a while, but the growth, I would think, the exponential growth that has occurred with HMP is pretty remarkable. So start from scratch and let everybody know what it’s about and how they tap into it. Then I have a couple other specific questions.
Cathy Milne: Okay. When we started, I think this was the only positive thing that happened during COVID. We were planning with Jeanne Cunningham and Miranda Henry, who at that point were running Kestrel Wound Care, a virtual conference, because a lot of people can’t get away to a conference. They have family responsibilities or work responsibilities, and travel and hotels can really add up.
So we were planning this, and we were going to debut in April of 2020. Guess what? There happened to be a pandemic, and nobody was going anywhere. We had a lot of people that first year because of the pandemic.
Then HMP acquired Kestrel from that group, and it’s grown exponentially. Dr. Shah is a wonderful man, and he’s so fun to work with. We get together and plan out what we think are really hot topics for people who can’t get to the conferences.
Some of it’s very basic. We’ve kind of paired with POSIC lately, which is the Post-Acute Wound and Skin Integrity Council, because a lot of people don’t get a lot of wound care information that is accurate, and it’s basic information.
So we have advanced courses and some basic courses, too, because we all know that 80% of the people who take care of wounds in the post-acute setting don’t have training that is very deep at all, if at all.
Dot Weir: Yeah, yeah, yeah. I’m going to come back to POSIC.
The other thing is that oftentimes people will contact me because if they have the CWS designation, they have to have six CEs every single year as they renew their membership. They have to take the test every 10 years, but they have to show that they’re current and getting some sort of continuing education in wound care. I always send them to WoundCon so they can tap into that.
So it’s usually spring—help me remember.
Cathy Milne: We have three symposia every year: spring, summer, and fall. For the ISS, the industry-supported sessions, they’re free. And now we have a small charge. It’s $49 for the day, or all day, and you get 15 CEUs. How cheap is that?
I don’t know about you, Dot, but I’m always scrambling at the end for my CEs because I’m usually the one giving stuff, not attending. So I’m scrambling and listening to all the lectures.
The nice thing is that for $99 for the whole year, you can get every single WoundCon for $99, so that makes it even cheaper. I worked it out to about 20 cups of coffee at Starbucks. For that, it’s worth it.
Dot Weir: So on the day that is for CEs, there are 15 credit hours over one day?
Cathy Milne: Yeah, because there are three tracks going at the same time. You can’t listen to all that in one day. You do it, and then if you get the $99 year package, it takes you the whole year. You can listen any time you need to.
I actually go back and listen to stuff. I’ll listen and think, “Oh, that sounded really interesting,” and then a couple months later, “What did he say again?” So I’ll go back.
Dot Weir: That is great. I never really realized that there were three tracks. I thought it was a singular track.
The industry-supported day—I’ve spoken in that a lot, and it’s great. It’s not just selling a product. The companies are always talking about the science behind their products. Yes, they have lights to keep on, but I’ve always found the integrity of those sessions to be very high. It’s not just a product presentation. It’s about the science behind them.
Cathy Milne: Yeah, and actually, they are one of the most popular because of the integrity. Yes, there’s product information, but it’s all about the pathophysiology and helpful tips.
So when you are using something or you see this clinical situation, you get these great tips from people like you so you can, as we say, learn today, apply tomorrow. That still happens in those industry-supported events, and they’re given by people who I think are trusted.
Dot Weir: Oh, yeah, absolutely. They’re usually not the people who work for the company. They usually ask speakers outside.
Cathy Milne: Yeah, they ask clinicians.
Dot Weir: People who are walking the walk and talking the talk.
Cathy Milne: Yeah. And Dr. Shah and I review these slides for their integrity before the ISS goes, because we don’t want somebody to stand up there and say, “Just buy this, buy that, buy this, buy that,” because that doesn’t help anybody.
Dot Weir: Yeah. So let’s say I’m a clinician and I think, “Gosh, I’ve just been exposed to XYZ product.”
Cathy Milne: You can just go to WoundCon. You can go to WoundCon.com. I’m sure it’s on HMP Global, too. You’ll be able to see the archives of past days of industry.
If you do want to know how this gadget works or learn more about it, you can go and see the past ones. I’d actually rather have people do that than go to TikTok or something like that, because you get some really wacky things.
Dot Weir: Oh, my gosh. I remember watching a sort of TikTok video that was all about how to put a negative pressure device on. I thought, “Oh my goodness, oh my gosh. How do you get these things taken down?” There was a bad technique anyway.
So yes, this is a much more credible place to go and find out how to use that.
Diane Krasner was a guest not too long ago, and I’m pretty sure we talked about PAWSIC. But between PAWSIC and CARS, in case they didn’t catch that one, let’s tell folks about those two organizations because I think they are so important and worthy, with two different reasons behind the organizations. Why don’t you tell us a little bit about both of those?
Cathy Milne: Good. Thank you so much.
PAWSIC is the Post-Acute Wound and Skin Integrity Council. Janine McGuire is the current president. Again, it’s really focused on advocacy for both patients and clinicians and staff in post-acute settings.
It’s really looking at long-term care and home health—not as much at outpatient clinics because they have a lot of advocacy. It’s talking about the regulations, talking about some of the clinical issues they see, and trying to give basic education to the group of people who work there.
What’s really cool about PAWSIC is that they really embrace that entire team. They have a board member who is a CNA, and he is absolutely wonderful because hearing that perspective can only help us as other providers to improve our patients’ outcomes.
Dot Weir: Education and advocacy, as you say, are so important. The bedside caregiver is the frontline set of eyes on these patients’ skin.
Diane did go into some detail, and I’ll tell the listeners: if you want to go back and listen to Diane, she did talk about all the work that you guys are doing with skin failure and working so diligently on the codes that will enable that to be recognized and clearly defined and described. Is that a good way to say that?
Cathy Milne: Really, the aim behind the skin failure project was because one arm of the federal government says, “If you have this, you can’t code it.” There’s no code for skin failure, but it exists.
In the real world, you see what another arm of the federal government describes as skin failure, but you can’t code it. There’s no code. It just says you don’t code it as a pressure injury, is what the regulations say. But what do you do?
So we’re just trying to get a code. I think it’s just the beginning of a number of things. The first thing is we need data. We need data.
If you’ve done everything for that patient—you’re turning them, you’re dealing with moisture management, you’ve put them on the right kind of pressure redistribution surface—and their skin has fallen apart and their blood pressure is 40, that’s probably skin failure. But we need to collect data. We just want to get the code. We just want a code so we can start looking at it, and everybody can start looking at the phenomenon.
Barbara Delmore has written a lot about this in the intensive care unit and has published, so we know that there’s something out there. Ever since the Egyptians, they recognized it. We just need to settle our differences and say, “Let’s just get a code.” Because it’ll be refined.
Just like we’ve just redefined the diabetic foot codes, right? Now we have each toe.
Dot Weir: Only you would know that. I don’t have to code.
Oh, you’re such a wealth of information.
So let’s flip over to CARS, because the first time I ever sat in an audience and you guys were up on the stage, I want you to describe what was on the table in front of us. Do you remember that?
Cathy Milne: Yes. When you look at the literature, we under-moisturize ourselves. It doesn’t matter if you’re a patient, a caregiver, or a health care professional. We just don’t use enough.
I think we had four coffee creamers, two medicine cups, and four ketchup packets on the table because you need one ounce twice a day for your entire body. That sounds like a lot. You’re thinking, “Oh my gosh, I have to go down to the store. I’m going to have to buy a tub.” Well, yeah, you probably will have to buy a tub.
There was a really cool article recently in Science that suggests that loss of skin integrity through transepidermal water loss, or barrier loss, may actually predispose you to dementia.
Dot Weir: Oh, my God. I just bought lotion at the grocery store today, so I’m so glad.
Cathy Milne: Even if it’s wrong, moisturize yourself.
One of the biggest things that we see with our leg patients is that they get all scaly. Scale, to me, is a transepidermal water loss skin barrier break.
So CARS, which is the Coalition for At-Risk Skin, is really looking at the thing that nobody reimburses, which is prevention. We can’t get people to buy it, right? They don’t want to buy moisturizers.
We need to look at barrier creams. We need to look at the impact of CHG, which I think is horrible on the skin. And we need to relook at that.
We’re trying to come up with educational infographics that people can download, put up in their bathroom, and hand out to their patients about how to moisturize and when to moisturize. This is just the start. We have a whole bunch of other projects we want to do.
Dot Weir: So a couple of things. It’s cars.org, and it’s free to join.
You were on the stage with Wendy Cawley at SAWC—or was that at WCM?
Cathy Milne: WCM.
Dot Weir: And you were talking about the one ounce twice a day. She made the funniest point that most of us can’t moisturize our back unless you have someone who will do that for you, so you may not need a whole ounce twice a day.
The thing that I’m keenly interested in and hope to work with you guys on is skin pH, and the importance of making sure that we’re focusing on not only what we’re putting on there, but the pH of the soaps as well as the moisturizers that we’re using.
Cathy Milne: Yeah. There are so many things that we subject our skin to that just ruin our pH, and what we’re doing is encouraging bad things.
Dot Weir: Yeah, yeah. As someone who grew up in Florida in the sun and just was in the sun yesterday for a couple of hours because I had an AACN meeting that I spoke at in Daytona Beach, Florida, I had a little time out by the pool and I just thought, “Oh my gosh, I’m going to pay for this.”
Go back to the CHG because I was going to speak to this AACN meeting, and I looked it up. There’s not a lot of negative in the literature about it, because they’re all about preventing line infections and things that are critically important when you’ve got a very sick individual with lines going everywhere in the body.
But it listed the pH as, I think, somewhere close to the normal range. So are you worried about it wiping out the microbiome? Is that what the issue is?
Cathy Milne: Yes. I don’t mind it wiping out a microbiome under a line, or at a line site. But typically what you see in a lot of hospital protocols is that they wash you from here down for three days.
Dot Weir: Oh, yes. That’s what I read. I was like, “Ugh.”
Cathy Milne: Yeah. That’s what I’m concerned about.
First of all, probably whatever survives is going from one area to another because they’re different bugs and things.
Dot Weir: Commensal bacteria.
Cathy Milne: Yeah. Bacteria here is different from your stomach and your pubic area and your feet. So what you’re doing is taking this—hopefully more than one sheet, but most likely probably two sheets—and you’re moving it down.
I think it’s something we need to really look at. I think there was just this shotgun approach to everybody getting septic in the ICU from colonization, and we have to save lives that way. But I don’t think there’s really been a huge critical look at whether maybe we need to target certain areas.
Dot Weir: Yeah, we call that north-to-south contamination.
Cathy Milne: I like that. I’m going to use that.
Dot Weir: Okay, you’re welcome to use that.
Well, Cathy, this has been such a pleasure. You are such a wealth of information and a good friend. Do you have any parting words?
Cathy Milne: No, I’m really glad that you invited me. I always love to talk to you. We could probably talk for hours.
Dot Weir: We could.
Cathy Milne: Yeah, we could. It’s an honor to be a difference maker. Thank you so much for having me.
Dot Weir: You certainly are. We’ll have you come back, and you and Diane and the PAWSIC group can come back as you learn more or accomplish more as far as the coding issues.
Thanks, everyone, for joining us. We’ll talk next time.
Bye-bye.
The SAWC Difference Makers Podcast is brought to you by the Symposium on Advanced Wound Care, one of the leading forums for advancing wound care education, research, and collaboration, and Wounds, the official journal of SAWC.