Why continuity of care breaks down at a change of setting
Wound care after discharge depends on a handoff. In the hospital, the wound is checked on a schedule, supplies are down the hall and orders reach the nurse quickly. On discharge day, all of that stops unless someone has arranged what replaces it.
Continuity of care means the plan survives the move: the next clinician knows what was done and why, the right dressings are in the home or facility, and the patient and family know who to call. Gateway coordinates those pieces with the treating practice and the teams on both sides.
Before the move: what to tell Gateway
The earlier we hear about a planned discharge or transfer, the more can be in place on arrival. Useful things to share when you call 314-325-0126:
- Where the patient is now, where they are going and the expected date
- The kind of wound and the care it needs now
- Whether home health, facility staff or family will handle care between visits
- A contact on the sending team and one at the destination
We use this to identify a treating practice that serves the destination and to request the records the clinician will need. Visit availability is confirmed by location and care setting.
What needs to travel with the patient
Whatever the destination, the same information should arrive with the patient or ahead of them:
- Current wound care orders and the discharge or transfer summary
- The latest wound measurements, if recorded, and a current medication list
- Names and phone numbers for the treating clinicians and the receiving team
- Supply and equipment needs, the supplier responsible and any pending requests
- Follow-up appointments already made, plus transportation needs
- The name of the person coordinating the move
Hospital staff can use the discharge planner wound referral checklist, and families the hospital discharge family checklist.
Hospital to home
At home there is no nursing station, and a family member often becomes the daily caregiver overnight. Before you leave, ask who will follow the wound, what to do with the dressing until the first visit, and which supplies you are going home with. If home health has been ordered, Gateway can help coordinate wound care alongside the home health agency so both teams work from the same orders. The service page on wound follow-up after hospital discharge has more.
Medications often change after a hospital stay too. Where it fits the patient’s needs, a partner clinician can provide transitional primary care after discharge.
Hospital to rehabilitation or skilled nursing
When the next stop is a rehabilitation center or skilled nursing facility, staff there take over daily wound care. The weak points are orders that arrive incomplete, a supply list without the dressing the hospital used, or uncertainty about when a wound clinician will visit.
Gateway works with the facility’s nursing team so the treating clinician has the hospital records and the facility knows what visit is planned. In a rehabilitation setting, wound visits also have to fit around therapy sessions, as the page for rehabilitation centers explains.
Rehabilitation or skilled nursing to home
The move home from a facility deserves the same planning as a hospital discharge. Facility staff have been doing the dressing changes, and the family may not have seen the wound in weeks.
If you will be helping at home, ask the facility for the current orders and the latest measurements, and ask whether you can be present for a dressing change before discharge day. Tell Gateway the planned date so follow-up and supplies can be arranged for the home address.
The first days after discharge or transfer
Once the patient has arrived, we help connect the receiving practice, facility or home health team with any information still missing, and we confirm follow-up arrangements with the patient or family.
Changes in the wound or in the patient’s condition go to the treating clinician. Report spreading redness, more swelling, warmth, increased drainage, a new odor, fever or worsening pain. If you are not sure who the treating clinician is yet, call Gateway. Call 911 for an emergency, such as bleeding that will not stop, trouble breathing, chest pain or sudden confusion.
Start a referral or request
Discharge planners and facility staff across Greater St. Louis and the Metro East can use the referral form or the referral email, [email protected]. Patients and families can use the request care form. The web forms collect contact details only.
Common questions
When should we contact Gateway about a discharge?
As soon as a discharge or transfer is being discussed, even if the date is not set. Early notice leaves time to identify a treating practice for the destination, request records and look at supply needs. If the patient has already moved, call anyway.
Who is responsible for the wound between discharge and the first visit?
Ask this directly before leaving. The discharge paperwork should include wound care instructions and say who to call with problems until a new clinician takes over. Daily care is carried out by the patient, a caregiver, home health or facility staff, as those orders direct.
What if the supplies sent home do not match the orders?
Do not substitute on your own. Call the treating clinician’s practice, or the office that wrote the orders, and describe what you received. Gateway can follow up with the practice and the supplier to correct the order. Keep the packing slip and note what is missing or different.
Does a patient need home health to get wound follow-up at home?
Not necessarily. Home health and visits from a wound care clinician are separate services with separate rules, and a patient may have one, the other or both. Whether home health is appropriate is decided by the ordering clinician and the agency. Gateway can coordinate with a home health agency when one is involved.