The gap between the nurse in the home and the order on file
Your nurses see the wound more often than anyone. They also know the frustration of a wound that is not responding, an order written weeks ago and an ordering office that is hard to reach. Wound care coordination with home health agencies is meant to close that gap. A treating wound clinician sees the patient at home, and the findings and orders come back to your agency in a form your nurses can act on.
Gateway arranges those visits with partner clinicians across Greater St. Louis and the Metro East. We coordinate the request, records, scheduling and communication. Skilled nursing visits stay with your agency, and clinical decisions stay with the treating clinician.
When agencies bring us in
- A wound has stalled or is getting larger under the current orders.
- The patient came home from the hospital with wound orders that are vague, outdated or missing.
- The ordering office does not manage wounds and would like a wound clinician involved.
- The patient cannot travel to a wound clinic, or keeps missing appointments there.
- A wound may need evaluation for debridement, negative pressure therapy or another treatment that needs a practitioner’s order.
- Your episode is ending and the wound is still open.
Who does what once a wound clinician is involved
These arrangements work when they are settled at the start. Our guide to home health and wound specialist roles covers them in detail. In brief:
- Your agency keeps the plan of care, skilled nursing visits, dressing changes, patient and caregiver teaching and its own documentation.
- The treating clinician assesses the wound, works out what is driving it, writes wound orders and decides whether tests, procedures or specialist referrals are needed.
- The certifying physician or practitioner continues to oversee the home health plan of care. Whether wound orders come straight from the wound clinician or route through that office is agreed up front, following your agency’s process.
- Gateway schedules the wound visits, moves records in both directions, follows up on unclear or unsigned orders and confirms who is supplying what.
Making visits and information line up
A wound visit is most useful when the clinician and your nurse are working from the same information. Before the first visit we ask for the current wound orders, recent visit notes and measurements, the medication list and the name of the nurse or clinical manager to contact. We also look at your visit calendar, so the clinician’s visit can fall on a planned dressing change day when schedules allow.
After each visit, the clinician’s note and any order changes go to your agency by the route you choose. If your nurse sees a change between visits, such as new odor or drainage, spreading redness, more pain or a wound that is suddenly deeper, the report goes to the treating clinician through the contact we set up. A short structured report helps, and SBAR for wound changes shows one format. In an emergency, the nurse or patient should call 911.
Supplies, the end of the episode and primary care
Duplicate or missing supplies are a common source of friction. Before anything is ordered we confirm whether dressings are coming from your agency, a supplier or another source. We also follow up on wound supplies and equipment that the treating clinician orders and that fall outside what your agency is responsible for.
When your episode is ending and the wound has not closed, tell us early. The treating clinician can keep following the patient, and we tell the patient and caregiver who to call once your nurses are no longer visiting. For patients with no primary care clinician able to follow them at home, Gateway can also arrange in-home primary care with partner clinicians.
How to refer a patient on your census
Call 314-325-0126, fax the referral and records to 314-786-7966, or use the referral form to ask for a call back. The web form is for contact details only. We confirm clinician availability for the patient’s address and let your intake contact know where the request stands. The home health wound care coordination guide is a companion to this page for your field staff.
Common questions
Can a patient see a wound clinician while on home health service?
The two do different jobs and are often in place together. Your nurses provide skilled nursing under the plan of care, and the treating clinician provides practitioner visits. Coverage is a separate question. Benefits depend on the treating provider, the patient’s plan and the care needed, so we raise it at the start of a referral and not after a visit has happened.
Whose wound orders should agency nurses follow?
The orders of the clinician responsible for that part of the plan, as agreed when the referral starts. If the wound clinician’s orders and the orders on your plan of care do not match, your nurse should not have to choose between them. Tell us, and we take the question to the treating clinician and the certifying office until one current set of orders is on file.
Does Gateway provide nursing visits between the clinician’s visits?
No. Gateway is not a home health agency, and a partner clinician’s visit does not replace skilled nursing. If a patient needs more frequent dressing changes than your current visit schedule allows, that is a question for the ordering clinician and your agency. Our comparison of home health and mobile wound care explains the difference for patients and families.
What if the agency’s own wound nurse is already following the patient?
Then the treating clinician has a well-informed colleague to work with. Your wound nurse’s measurements, photos taken under your agency’s policy and observations over time are valuable at the first visit. The clinician adds what requires a practitioner: diagnosis, orders, procedures and referrals. Give us your wound nurse’s direct contact and we route visit notes and questions there.