Why the LTACH discharge is a hard handoff
A patient in long-term acute care may have had weeks of daily wound attention: wound nurses on the unit, a specialty bed, negative pressure therapy, a dietitian adjusting tube feeding. Discharge moves that patient to a setting with fewer hands and less equipment, often in a single afternoon.
Wound follow-up after long-term acute care is about what happens on the other side of that move. Gateway Wound Care arranges visits from partner clinicians in homes, skilled nursing facilities, rehabilitation centers and assisted living across Greater St. Louis and the Metro East. We coordinate the records, orders, supplies and scheduling that carry the wound plan to the next setting, as our continuity of care page describes.
What the next setting needs to know
A discharge summary rarely holds enough wound detail for the people who inherit the patient. The handoff works when it includes:
- A wound-by-wound list with location, type, most recent measurements and the date they were taken
- Current dressing orders and how often each wound is dressed
- For a pressure injury, the stage, the support surface in use and the turning plan
- Negative pressure therapy details: settings, date of the last dressing change, and whether a device has been arranged for the next setting
- Culture results, the antibiotics in use and their planned stop dates
- The nutrition plan, including tube feeding orders
- Surgical history that limits positioning, such as a recent flap, and the surgeon’s follow-up date
- Skin concerns around a tracheostomy, feeding tube or ostomy
- A name and direct number at your hospital for questions after discharge
Our guide to the wound care discharge handoff covers discharge to home in more detail.
Start before the discharge date
Call when discharge planning begins, even if the date and destination are not settled. Early notice lets us confirm whether visits are available at the likely address or facility, request records while your team is still caring for the patient, and identify equipment that takes time to arrange.
Availability is confirmed by location and care setting, and we do not promise timing. We will tell you plainly where a request stands.
Discharge to a skilled nursing or rehabilitation facility
Many LTACH patients with large wounds move to another facility first. There, the attending physician and facility nurses carry the daily wound care, and a visiting wound clinician can add regular assessment through facility wound rounds.
Give us the receiving facility’s name and an admissions or nursing contact. We coordinate with the facility on visit arrangements and on getting your wound documentation to the visiting clinician. The facility remains responsible for its own nursing care, staffing and supplies.
Discharge home
Going home from an LTACH puts the wound in the hands of family, usually with home health nursing. The questions are practical. Who will do dressing changes on the days the nurse does not come? Are the bed and mattress in place? Are supplies in the house for the first week?
Gateway coordinates wound visits by a partner clinician alongside home health, and works with the agency so both follow the same orders. We also handle wound supply and equipment coordination tied to the treating clinician’s orders. If negative pressure therapy is continuing, see our page on wound VAC therapy at home for how the device, supplies and visit schedule are lined up.
What Gateway coordinates and what it does not
We coordinate the request, the first contact with the patient or family, records, visit scheduling, delivery of orders to the people carrying them out, supplies, transportation arrangements for outpatient follow-up, and communication among the teams.
We do not make clinical decisions. The treating clinician at the next setting assesses the patient and decides on diagnosis, orders and treatment, and may change the plan your team wrote. Gateway does not decide coverage either. Participation and benefits depend on the treating provider, the plan and the care needed. Gateway is not an emergency service.
How to refer from an LTACH
- Call 314-325-0126 or fax 314-786-7966. You can also send a referral request online, which takes contact details only.
- Tell us the expected destination and the patient’s or family’s contact information.
- Fax the wound documentation, medication list, recent labs and discharge orders when they are ready.
Common questions
What if the discharge destination changes at the last minute?
Tell us as soon as you know. Coordination follows the patient, so a switch from home to a skilled nursing facility, or the reverse, means we check availability for the new setting and redirect records and supply requests. Equipment arranged for one setting may not transfer to another, so early word leaves fewer loose ends on discharge day.
Can negative pressure therapy continue after discharge?
That depends on the treating clinician’s orders at the next setting, the equipment and the patient’s coverage. The hospital’s device often stays with the hospital, so a device for the next setting has to be arranged before discharge to avoid a gap. Tell us early that the patient is on negative pressure therapy, and include the current settings in the records.
Who writes wound orders after the patient leaves?
Your discharge orders go with the patient. From there, the clinicians at the next setting take over: the attending physician and nurses at a facility, or the treating clinician and home health agency at home. A partner clinician who sees the patient makes their own assessment and writes orders based on what they find.
Can primary care follow-up be arranged along with wound care?
Ask when you refer. Patients leaving an LTACH often need medications reconciled and chronic conditions checked soon after they arrive at the next setting. Gateway can coordinate follow-up care after discharge with a partner clinician, subject to availability for the location. If the patient already has a primary care clinician, we send records there instead.