Transitioning wound care patients to post-acute care

    Author(s): Armi S. Earlam, DNP, MPA, BSN, RN, CWOCN; Lisa Woods, MSN, RN-BC, CWOCN; and Kari Lind, BSN, RN

    transition wound care patients post acute

    Setting goals and meeting needs.

    Takeaways:

    • When discharging patients from acute care facilities, consider cognitive and functional status; the home environment; family or caregiver support; access to services, medications, and transportation; and follow-up care.
    • Depending on the patient’s situation, the three goals of wound care are healing, maintenance, and comfort.
    • After discharge from an acute-care facility, patient medication management, diet, and lifestyle can help support wound healing.
    • Patient and family engagement and education, including their goals, preferences, and concerns, are fundamental to a successful transition.

    By Armi S. Earlam, DNP, MPA, BSN, RN, CWOCN; Lisa Woods, MSN, RN-BC, CWOCN; and Kari Lind, BSN, RN

    Discharge to post-acute care settings such as rehabilitation and skilled nursing facilities, long-term care hospitals, and home health depends on the patient’s overall health. Other factors that must be considered include the patient’s cognitive and functional status; the home environment; family or caregiver support; access to services, medications, and transportation; and follow-up care. In this article, we’ll focus on the needs of wound care patients who are transitioning to post-acute care.

    Elements of a wound care discharge plan

    transition wound care patients post acute 350When discharging a patient who needs wound care, acute-care clinicians (wound care nurse, discharging nurse, and case manager) should evaluate the comprehensive wound care plan, asking questions related to the goals of care, discharge setting, care provider, products and resources, patient factors that influence wound healing, and follow-up care.

    What are the care goals?

    Depending on the patient’s situation, the three goals of wound care are healing, maintenance, and comfort. If the goal is wound healing, treatment should focus on wound granulation and eventual closure. However, if the wound is unlikely to heal (for example, an elderly patient with arterial wounds who is too frail for a vascular intervention), the goal is to keep the wound clean, stable, and free of infection.

    For patients receiving end-of-life care, comfort is the goal. Treatment includes dressings that are changed less frequently, cause less pain, adequately absorb drainage, and control foul odor.

    Keep in mind that goals may overlap and evolve, so the wound care plan should be modified as necessary.

    Where will the patient go?

    Wound severity and complexity may affect the choice of post-acute care setting. For example, a patient with multiple wounds requiring either negative pressure wound therapy (NPWT) or twice-daily dressing changes may be best placed in a long-term care hospital. On the other hand, someone who needs once-daily wound packing can be managed at home if the patient or family can perform dressing changes between home health nurse visits.

    Additional considerations include clinician time needed to perform wound care and equipment availability. Some post-acute care settings may not have the resources for frequent dressing changes or clinician visits. The discharging facility must establish that the necessary equipment and clinical personnel are available.

    Who will perform wound care?

    Clinicians need to assess whether the patient is functionally and cognitively able to perform wound care. If not, other options include a home health nurse or a family member or friend. If the patient lives in a remote area and wound care will be done by a family member with only periodic visits by a home health nurse, the in-patient nurse needs to assess the caregiver’s ability to complete care tasks and provide education. The teachback method allows caregivers to demonstrate what they’ve been taught so the home health nurse can assess comprehension and ability.

    If the patient is being discharged to a setting other than the home, the facility must demonstrate the availability of clinicians who have the knowledge and skills to manage the prescribed wound therapy.

    What products and resources will the patient need?

    Each facility and agency has its own formulary of wound care products; the brands used in the hospital may not be the same used in post-acute care. The patient’s insurer also may dictate what products will be used. For example, different manufacturers of NPWT products have contracts with different insurers, which will dictate what brand can be used at home.

    Insurance companies reimburse home health agencies a set amount depending on the patient’s diagnoses. Daily dressings or costly products may not be feasible after acute-care discharge. However, an expensive product that requires twice-weekly dressing changes rather than twice-daily saves clinician time, making it a more cost-effective choice. Alternatively, substituting a less-expensive comparable product or therapy for an expensive one without loss of efficacy may facilitate a timely transition.

    What patient factors should be addressed?

    After a patient is discharged from an acute-care facility, medication management, diet, and lifestyle can help support wound healing. For example, patients with diabetes who have foot wounds must control their glycemic levels by following medication regimens and dietary recommendations, and patients who smoke should begin a cessation program. Patients with heart failure who have leg swelling and blistering that results in wounds must adhere to their diuretic therapy. To avoid infection that can impede wound healing, all patients must adhere to prescribed antibiotic regimens.

    When treating pressure injuries, addressing the etiology is crucial. Clinicians or family members may be using the appropriate wound care products, but if the affected body part is not properly offloaded and pressure not redistributed adequately, then the wound treatment will be futile. For example, a pressure injury on the heel won’t improve if the cause of the pressure isn’t addressed by using offloading boots or pillows under the calves when the patient is resting in bed.

    What are the follow-up care plans?

    Discharge instructions should include detailed wound care guidelines and contact information for the provider with whom the patient should follow up. Plans for future supply procurement, conditions for revising the care plan, and access to transportation for follow-up care also should be considered.

    Successful transitions

    Safe and effective care transitions not only are best practices, but they’re also essential in today’s healthcare environment. Changes in reimbursement, including both incentives and penalties for certain discharge outcomes, along with a much-needed emphasis on quality, accountable care have encouraged this attention. Patient and family engagement and education, including their goals, preferences, and concerns, are fundamental to a successful transition. Nurses can help ensure that treatment goals and patient needs are met by providing support, education, and care.

    The authors work at Lutheran Medical Center in Wheat Ridge, Colorado. Armi S. Earlam is the lead certified wound ostomy and continence nurse, Lisa Woods is a certified wound ostomy and continence nurse, and Kari Lind is an RN working in wound and ostomy care.

    Selected references

    Adkins CL. Wound care dressings and choices for care of wounds in the home. Home Healthc Nurse. 2013;31(5):259-67.

    Agency for Healthcare Research and Quality. Care Transitions from Hospital to Home: IDEAL Discharge Planning: Implementation Handbook.

    Alper E, O’Malley TA, Greenwald J. Hospital discharge and readmission. UpToDate®. April 3, 2017.

    Dreyer T. Care transitions: Best practices and evidence-based programs. Home Healthc Nurse. 2014;32(5):309-16.

    Hudson R, Comer L, Whichello, R. Transitions in a wicked environment. J Nurs Manag. 2014;22(2):201-10.

    Krapfl LA, Peirce BF. General principles of wound management: Goal setting and systemic support. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society® Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016; 69-79.

    Milne C. Challenges of transitioning wound patients through the continuum of care—Q & A. November 2016.

     

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    6 COMMENTS

    1. That is a good point that wound care should have healing and maintenance. It would be nice to have some products that could help someone do that. If I ever have wounds, I would want to have some good care products.

    2. Something I didn’t know was that dieting and lifestyle can help wound healing support. That is something I would love to make better if I had a bad wound. It would be good to go to a wound care clinic to help me figure out what would be the best options for myself.

    3. I agree with Mary – as an independent nurse practitioner in wound care who sees patients across the continuum, using services in the post-acute setting can be beneficial to both the patient and the facility. My practice does this, as do many others. Post-acute settings have many choices regarding providers in wound care. It is very important for the facility to examine the credentials and experience of the providers. Not all certifications in wound care have accreditation – thus, if an accredited certification is important o that organizations, one must be familiar with what “those letters” are. Ask for references, too. Speak with other facilities who have had that provider. Ask for the CV of the provider. Ask if the provider has a working relationship with other care settings that the post-acute patient may be coming from or going to….all of these aspects help transition the patient safely AND economically across settings.
      Catherine Milne APRN, MSN, ANP/ACNS-BC, CWOCN-AP

    4. This month’s issue of American Nurse Today caught my attention with the article entitled “Transitioning wound care patients to post-acute care.” This excellent article is to be applauded as it helps build increased awareness about what to consider in evaluating the discharge plan of care for patients with wounds. Too often it seems once dressing orders are written, it is assumed that ‘at least the wound care part’ is done.

      The authors rightly point out that the challenges and potential pitfalls of ensuring delivery of evidence based care across the continuum often require a near herculean balancing act between available resources and patient needs. I believe this article is important because it emphasizes key factors to be considered in the transition plan beyond dressing change orders. Since outcomes, quality and costs of care are driving forces in health care, the impact of outcome measures including time to heal and reduced frequency of complications will certainly be affected by where the patient goes and what resources will be available after they arrive. Going forward, we are reminded that wound care discharge outcomes will be used to measure quality and impact reimbursement, incentives and penalties.

      A number of key considerations are mentioned by the authors including: “identification of care goals, who will perform wound care, what products and resources will be needed and what particular patient factors should be addressed.”1 I would like to offer that there is yet an additional post- acute resource for wound care patients that should be considered by care transition planners. Some Home Health, Skilled and Long-Term Care facilities have opted to partner with an independent wound care specialty physician or provider group which ‘brings expertise to the bedside, rounding weekly with staff with less disruption of the resident’s day, less pain, lower costs of transportation to outside facilities.’2 These specialty groups also provide staff education, promote collaborative care and are associated with better survey results. Examples of these groups include: “Advantage Surgical and Wound care, Ameriwound, Skilled Wound Care, Vohra Post Acute Physicians, Coast to Coast Wound Care Surgeons, Physician Wound Associates” and more recently, United Wound Healing.3

      Although post-acute care settings or agencies may not have sufficient internal resources to address the needs of patients discharging with complex wound and skin issues, I would encourage readers to consider looking for those settings which partner with a wound care specialty group which can provide a bridge to achieving successful outcomes, often at no extra costs to the facility or agency.

      Mary Nametka, MSN,RN,CWS,CWON,CFCS,FNP-BC

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