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My name is Jeanine Doty, RN and I have been in the compression field for over 25 years, and like many areas in healthcare, I have seen tremendous growth and advancements. When I first started, there was limited awareness and product availability for patients with lymphedema or lipedema compared to today, we have significantly more options.
Manufacturers responded to requests from people and us around the country to develop and produce new garments for lymphedema patients. I have been fortunate over the years to work with several companies on product development.
During this time, there was a lot of trial, error, and experimenting to see what might work. It helped to have a background in nursing, but working as an Orthotist and Prosthetist, I was able to use our manufacturing lab to create and modify garments for patients. Twenty-five years ago, we were much more dependent on compression garments initially designed for vascular or burn patients.
Now we have products specifically designed for patients with lymphedema and lipedema. So now, not only do we have more garments available but also how and when we are using them has changed. Now with so many garment options, we must think about what garments to use, when to use them, and most importantly, make sure they are fitted correctly and work well.
Compression Garments are Vital in the Treatment of Lymphedema
Before I go on to the various garments and their use and care, I want to bring up a critical point; in fact, this might be the most important thing to remember about compression garments. Compression garments are vital in the treatment of lymphedema and lipedema, and the time to discuss compression garments is at the initial consultation with the therapist and during the development of the treatment plan.
When Should We Talk About Compression?
During the initial evaluation, the patient must understand they will need to wear compression garments to maintain or control their edema. If they are not committed to wearing them, do not have the assistance to donn or doff, or do not have the insurance coverage or funds to pay for them, they should not go through a treatment program at that time. It is unfair to the patient, insurance company, and therapist to not have this part of the treatment plan figured out to start. If, for some reason, they do not get their garments, all the time and effort can be wasted, and they can swell again.
Compression garments are the "medicine" for lymphedema. So patients need to take the steps necessary to get them. They may need to budget for them, request assistance, change insurance, or ask for help from friends and family because neglected lymphedema is much more uncomfortable, higher risks and is more expensive and difficult to treat.
It is vital to work with a fitter or Orthotist with clinical experience in compression garments and make sure they carry a wide range of products. This person should be brought in to the initial treatment planning to assess the patient's abilities to use compression garments, determine insurance coverage, discuss options, and get the process started. Which means to verify benefits, get prescriptions or authorizations, and possibly order specialty garments. Some insurances offer limited coverage, either a dollar amount or quantity, meaning careful planning needs to take place to get the best value from their benefits.
Insurance Companies want Outcome-Based Care, Are the Goals being Met?
Insurance companies are looking at outcome-driven care. If a patient is not committed, I promise you will not get a good outcome. It is essential to establish realistic goals. It is much better to succeed in small goals than to fail in meeting a bigger purpose.
The better goal might be to design the treatment in stages. The goal of the first stage might be to reduce the lower extremities, provide a hybrid wrap/compression garment so they can begin to be more mobile. Then have them return in 6 months or a year. If they have been compliant in wearing their garments, then move on to the upper leg, then in another six months move toward the hips and abdomen.
With hybrid garments, this method of staged care is very successful not only clinically but financially. No one wants to pay for unused garments. It is all about value-driven care.
Within the last few years, health plans, including Kaiser, the VA, and even local insurances such as Presbyterian, have reached out asking for our help to reduce costs for compression, as well as to continue to provide top clinical care. My first reaction, "what? You want us to not provide the best for your patients?" But I understand why it needs to happen, and we must work together to manage costs.
Then: Fewer options with higher cost VS. Now: More Options with Less Cost
My biggest motivator for reducing costs is to make sure benefit coverage doesn't become reduced or eliminated for lymphedema patients. That means the price reduction had to be significant enough to make a difference in the health plan. Health care costs are high for everyone, and we must work together.
So, to address the requests of the health plans, I went back to my roots of creating different ways of providing garments. So instead of not having the garment choices, it becomes, how can we use all products available to provide value-driven care?
Also, in the past, we would often need to use custom made garments to get the necessary control and coverage. Now we have many more product designs and extended size ranges in readymade garments.
Reducing Costs for Compression Treatment
To achieve the goal of reducing costs, we used hybrid compression designs, increased the use of newer readymade products, and set more realistic goals. When I talk about hybrid designs, I mean using custom and non-custom garments together, not staying brand specific and making garments have a multipurpose use. Then the challenge became how to promote or facilitate the change in patient care with therapists, fitters, and patients.
Example: Our Kaiser patients had a 30% reduction in costs
I am proud to say in 2017; we tracked our Kaiser patients for the year. We found we had reduced the Kaiser average cost per patient by 30% without any complaints about the quality of our care, which is significant since we are the largest provider of compression for the Kaiser system.
As we pushed to make changes in compression fittings, we noticed other benefits. These newer designs and hybrid accessories were saving therapists and patients time, and some patients even became more compliant.
For example, in the past, if a patient was fortunate to be treated by a therapist skilled in lymphedema work, the standard of care was to use multilayer bandaging and massage, then provide garments at the end of treatment to maintain or prevent swelling. Now we are often providing garments at the beginning of treatment that can replace some or all the bandaging during the reduction period. The Medi Reduction kit, the Sigvaris CompreFlex reduce garments, Jobst Farrow wraps are great examples used to reduce edema.
Let's Talk Reduction
Medi states our company is the only compression provider in the western half of the united states that is fitting the garment for the therapist. We will do the initial fitting, which can save the therapist significant time. Then the trimming that needs to take place as the patient reduces is done during the therapist treatment time.
In California, we had a therapist complain that we did not fit them correctly because they were too big. She was having the patient come back after two weeks of the initial fit. The garment did its job and reduced the arm, so of course, it was too big. But she didn't remember she had to see them in the next day or two. Now we will do the fitting and trimming, remove the garment, and have them start wearing it after the first therapy treatment.
Other products that can assist with the reduction phase of treatment are various pads like swell spots or chip bags or sheets of wave foam or channel foam, which can help break up fibrotic or thickened areas to get the fluid moving. The therapists used to make these pads, but it can be very time consuming and take away valuable treatment time.
Using a Combination of Bandages, Reduction Garments, Pads, and Elastic Garments
Sometimes you might use a combination of bandages, reduction garments, pads, and elastic garments. It also might be appropriate to use various brands. For example, for one patient, I used a Jobst Cicatrex glove with a Solaris swell spot and Juzo wrap gauntlet and a Farrow OTS Arms wrap. Another good suggestion is to use finger bandages, which are easy to self-wrap, with a gauntlet wrap and a reduction arm kit.
Patient Decision Making:
Cost, Donning, Comfort & Appearance
For maintenance garments, utilizing this concept, we are more creative in our thinking. Can the reduction garment be also used as a night garment? Can wraps be used for mild reduction, can we use wraps over circular knit for more control? Instead of full custom garments or wraps can we use add on garments for greater control just where it is needed? For example, using a shelf strap or fitting custom flat knit knee highs and circular knit capris.
Compression garments can be expensive, and so patients must be utilizing their insurance benefits. The insurance billing is very complicated for compression, making it very hard for patients to submit claims directly.
Because these garments can be expensive, it is essential to take proper care of them. This means washing them after each use. Never using bleach or fabric softener, don't dry in the sun, or wring or stretch the garments.
Elastic garments need to be replaced every six months or more often if needed. If they become easy to get on, they need to be replaced.
Last week, the VA ordered full custom thigh wraps, and we suggested just making the right calf piece custom due to the size, and the rest could be readymade. This resulted in significant savings.
Time of Day is Important
So we know wearing compression is important, but of equal importance is knowing when to fit the patient. If garments are being used to reduce, they might be fit even before therapy begins. But maintenance garments need to be fit after a patient has reached a plateau. Or as I like to call it "as good as it gets for now." Maintenance garments are not designed to reduce but are meant to keep the edema from coming back. From a financial standpoint, we don't want to use up insurance benefits or a patient's finances it the garment will be too big after treatment.
Patients who are self-monitoring should come in for measurement when they are at their smallest. That could be first thing in the morning, or after they have self wrapped. It is relatively common that we turn a patient away and ask them to wrap or return when they are smaller in size or as good as they think they can get.
I think the patient must be involved in the decision-making process, as well. What is the most important thing for the patient? Is it cost, comfort, or ease of getting on? Maybe it is the appearance or even the texture. Many patients have a bad memory or experience with wearing compression garments, so allowing them to participate in their care will improve compliance.
One of the best ways to provide value-based care is by assuring a proper fitting garment. If a patient has just finished three weeks of lymphedema treatment, you want to make sure they are fit in the right garment and size not only to maintain the limb size but also to prevent complications. With good intentions, some therapists might give a patient a sample garment to save money, or a patient tries to self-measure and fit. It can cause more swelling if it is a poor fit; you don't want to lose all the gains made during treatment. Here are some examples of what can happen.
I worked with a therapist whose goal was to reduce patients enough, so they fit into a readymade circular knit garment, regardless of the stage of their lymphedema or their body shape. She thought thinner, and softer garments would be more comfortable and more cost-effective. The problem was her patient compliance was low. The thinner garments are more irritating increases and didn't contain the edema. Also, the patients were uncomfortable and didn't want to wear them.
By switching to flat knits and wraps, her compliance and outcomes improved significantly. When patients could not afford custom made flat knits, we were able to utilize readymade wrap garments.
In closing, what I hope what you take from today is understanding the importance of well fit, appropriate compression garments in the treatment of lymphedema. Knowing that there are many new garments available, we must be creative and innovative in how we use them to provide value-based care.
At Active Life we care about our patients. Our goal is to help patients with lymphedema succeed in their compression treatment. If you or someone you know needs help or extra guidance, we are your resource. Contact us today!