A follow-up plan the patient can name before leaving
A discharge summary that says to follow up with wound care does not tell the patient who is coming, where, or who to call when the dressing will not stay on. Post-discharge wound care referrals in St. Louis come to Gateway from case managers who need that next step filled in before the patient is out the door.
Gateway connects the patient with a partner clinician who can see them where they are going and coordinates the practical details of wound follow-up after a hospital stay. After discharge, the treating clinician makes the clinical decisions.
Matching follow-up to the destination
- Home with home health. The agency keeps its nursing visits and the partner clinician provides assessment and orders. We confirm who is ordering and who is supplying dressings.
- Home without nursing. We ask who will do dressing changes, what teaching the caregiver received and what supplies went home.
- Skilled nursing or rehabilitation. We ask whether the facility already has wound rounds and coordinate with its nursing team.
- Assisted living or memory care. Visits are arranged in the resident’s apartment, with the community and family informed as the patient permits.
Availability is confirmed by location and care setting, in Missouri and in the Metro East. The service area page lists the communities we coordinate in.
What to send with a referral
- Patient name, date of birth, phone number and the address the patient is going to.
- Anticipated discharge date and destination, with a contact at a receiving facility or agency.
- Coverage information.
- Discharge summary or history and physical, current wound orders and the inpatient wound nurse’s most recent note.
- Operative notes for surgical wounds, and details of any negative pressure device going home with the patient.
- What is already arranged: home health, supplies, surgeon or specialist appointments, transportation.
- The caregiver’s name and number, and your direct line.
Fax referrals and records to 314-786-7966, or call 314-325-0126. The referral form on this site takes contact details only, so use it to ask for a call back and keep clinical information out of it. The discharge planner wound referral checklist covers the same ground in more detail.
What happens after you refer
We review the referral against clinician availability for the patient’s location, care setting and coverage, then contact the patient or caregiver to arrange the visit. We tell you where the request stands so you can document the plan. If we cannot place the patient, we say so, so you are not left waiting on us.
Visit timing is confirmed case by case and we do not promise it in advance. A patient with an urgent wound concern at discharge needs a plan from your team that does not depend on our scheduling.
We also help assign the open items: who receives the records, who confirms the visit, who handles supply requests and who follows up with the patient or receiving facility. Our page on continuity of care describes Gateway’s role as a patient moves between settings.
What stays with the hospital and with the treating clinician
Your team owns the discharge: the orders, the patient and caregiver teaching, the first supplies, the surgeon’s follow-up appointment and the decision that the patient is ready to go. Gateway does not change any of that.
Once the patient is seen, the treating clinician assesses the wound in its new setting and writes orders going forward. The plan may change from what was written at discharge, because the clinician is looking at the wound, the home and the help available. Visit notes can go to the surgeon or primary care office the patient names.
Primary care in the first weeks home
Patients with wounds often leave with medication changes, new diagnoses and no realistic way to get to an office. Gateway can coordinate transitional primary care after discharge with partner clinicians for patients who need medical follow-up at home alongside wound care.
For teams working on return-to-hospital risk, our guide on readmission risk and wound follow-up looks at where wound handoffs tend to break down. Families can use the hospital discharge checklist for families at the bedside.
Common questions
How early should a wound referral be sent?
As soon as you know the patient will need wound follow-up, even if the discharge date is still an estimate. An early referral gives us time to check clinician availability for the destination, gather records and reach the caregiver. You can start with the anticipated date and destination and update us as the plan firms up. We do not promise a visit by a particular day.
Can the patient or family call Gateway themselves after discharge?
Yes. Patients, family members and caregivers can call 314-325-0126 with or without a referral, and some teams add the number to the discharge instructions. If records were not sent, we ask the patient for permission to request them. A referral from your team is still the more reliable route, because the orders and discharge summary arrive with it.
Can you confirm that the patient’s plan will cover follow-up visits?
No. We can talk through questions about Medicare, Medicare Advantage, Medicaid and commercial plans, but participation and benefits depend on the treating provider, the plan and the care needed. Sending coverage information with the referral lets the treating practice review it before the visit, so the patient hears about any coverage issue early.
What if the destination changes on the day of discharge?
Call us. A patient who was going home and is now going to a skilled nursing facility, or the reverse, needs a different arrangement. We recheck clinician availability for the new location and care setting, redirect the records and tell you whether the earlier plan still holds. Arrangements made for one address do not automatically carry over to another.