Case Manager Guide to Mobile Wound Care

Start with the access problem

This case manager guide to mobile wound care is organized around the two decisions you make on a wound referral: whether the patient fits, and what to send. Fit usually has less to do with the type of wound than with one plain question. Can this person reliably get to a clinic, week after week?

Mobile wound care moves the visit to the patient. Gateway arranges visits from partner clinicians in homes, assisted living, memory care, skilled nursing and rehabilitation settings across Greater St. Louis and the Metro East, and coordinates the work around each visit. The treating clinician makes every clinical decision.

Patients who tend to fit

People who miss wound clinic appointments because of rides, stairs, weather or a caregiver’s work schedule
People for whom leaving home takes two helpers, a wheelchair van or most of a day
People with long-standing wounds that need regular reassessment, such as pressure injuries, leg ulcers and diabetic foot ulcers
People recently discharged with a wound and no follow-up they can physically reach
People with dementia or anxiety who do poorly in a busy clinic
People with home health in place but no clinician directing the wound plan

Being homebound is not the test for every visit at home, as our explainer on what homebound means describes.

Patients who need something else, or something more

Someone acutely ill. Spreading redness with fever, heavy bleeding or new confusion needs urgent evaluation. Gateway is not an emergency service. In an emergency, call 911.
Someone who needs testing or a procedure. Vascular studies, imaging and surgery happen elsewhere. Mobile visits can continue alongside, and Gateway helps with vascular and specialist referral coordination when the treating clinician orders it.
Someone who does not want visitors at home. We confirm with the patient or their representative before anything is scheduled.

What to send with the referral

Send what you have from this list:

Where the patient will be. The address where they will be living, which is not always the address on file, plus entry notes such as stairs or a door code.
A phone number that gets answered. Include the family contact or decision maker and any language or hearing needs.
The plan. Payer, member number and any authorization requirements you already know.
The wound. Location, how long it has been there, recent measurements, current dressing orders and who changes the dressing.
Recent notes. Discharge summary, the last wound clinic note and an operative note for surgical wounds.
Medication list and allergies.
Related conditions and results. Diabetes, circulation problems, mobility limits, and any recent labs, cultures or vascular studies.
Who else is involved. Primary care, specialists, home health agency, hospice, equipment supplier.

Short on time? Send the address, a working phone number, the plan and the wound location. The rest can follow.

Call 314-325-0126, fax 314-786-7966, or use the referral request form. The form takes contact details only. Clinical information goes by phone or fax.

What happens after you send it

We contact the patient or family, confirm they want the visits and check availability for the address. A partner clinician sees the patient, and Gateway coordinates the resulting orders, supplies and follow-up.

We do not quote timelines, because availability is confirmed by location and care setting. We can tell you where the request stands, what is missing and who has it. Our page for case managers and health plans describes the status you can expect.

We never say that a plan is accepted or a service is a covered benefit, because that depends on the treating provider, the plan and the care needed. Name the plan at intake, and see the insurance page for questions members can ask.

Habits that keep a referral from stalling

Dial the patient’s number yourself before you send it.
Tell the patient to expect a call from Gateway, possibly from a number they do not recognize.
Name one family contact, not three.
Give the discharge date and destination, and update us when either changes.
Name the home health agency so both teams work from the same orders.
Put a follow-up task on your own list.
Mention it if the patient has no primary care. In-home primary care may be available for the same address.

For a facility resident, ask whether the building already has facility wound rounds. Adding a resident to an existing round is often simpler than a separate visit.

Common questions

What if I do not know what kind of wound it is?

Refer anyway. Describe what you do know: where the wound is, roughly how long it has been there and who has been caring for it. Working out the cause is part of the treating clinician’s assessment. A referral held back for a missing diagnosis usually just delays that assessment.

Can mobile wound care and home health be in place at the same time?

Often, yes. A home health nurse provides skilled visits under the agency’s plan of care, and a wound clinician assesses the wound and directs the treatment plan. How each is a covered benefit depends on the plan. Our comparison of home health and mobile wound care explains the difference.

The patient is hard to reach by phone. Should I still refer?

Yes, and tell us how to reach them. Give a family member, neighbor or facility contact, the best time of day, and whether the patient answers unknown numbers. If we cannot reach anyone, we will let you know so the referral does not sit unnoticed.

Who decides how often the wound clinician visits?

The treating clinician sets the visit schedule based on the wound and the plan of care, and it can change as the wound changes. Gateway does not promise a visit frequency before the clinician has seen the patient. If your care plan needs visit dates, tell us and we will report them as visits are scheduled.

Updated October 2026

A case manager guide to mobile wound care.