Managing expectations for patients and their caregivers who are being transferred from one care setting to another can be difficult to navigate related to wound care. Wound care standards are in place to provide safety and promote healing through the transition process. As the patient transitions from the site of care to home, there are many things to consider for both the discharging site, patient/caregiver, and home health agency.
Challenges During the Transition from Hospital to Home
Transitions in care for wound patients to home care can be tricky. The wound care segment of home care has become more competitive with the 2020 rollout of PDGM (Patient-Driven Group Model) which takes into consideration co-morbidities and severity of the wound. When discharge orders are ready and have been entered into the EHR system, the social worker is already working on placement for the patient. When being discharged to home the patient has the option to choose what home care provider they wish to use. Often, they will resume care with an already established home care provider which can make the transition easier, however, there are still several obstacles to overcome.
The discharging facility will send resumption of care orders or a new start of care orders to the home care agency, which must be reviewed by the agency. Upon discharge, the patient will need to be restarted or started within 72 hours to receive the maximum reimbursement and is considered an early episode. In order to maintain continuity of care the discharging facility will complete a wound dressing change the day of discharge and will sometimes send “take-home” dressings with the patient to tie them over until the home care agency starts or restarts them.
Communication is Key During Transitioning
Communication is key in this part of the transition as most home care agencies do not keep stock of extra wound care dressings. When care is resumed or started the treating physician of record will sign off on new orders and the plan of care will be updated to reflect wound care to be provided and the frequency of visits by the home care staff. According to standards of care for home care agencies wounds should be assessed weekly along with wound photos by competent and trained skilled nurses. Sadly, consistent education, standards of care, and continuity miss the mark with home care agencies. Any change in the status of the wound should have documented interventions, care coordination notes, and communication with the treating physician and patient/caregiver.
The shift for patients to return home has been at the forefront of health care for a while now. In an effort to continue this paradigm, it is important to make sure the patient remains the focus of care and the road to recovery is free of as many obstacles as possible. When navigating the path home continuity of care, communication and preparedness are all important factors to make sure patients are discharged with the correct orders, wound care dressings are available and competent nurses are available to assume care.
Future Reading and References
Agency for Health Care Policy and Research, U.S. Department of Health and Human Services
CMS. (n.d.). Home health patient-driven groupings model. CMS. Retrieved February 3, 2022, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM