Wound follow-up for teams working to reduce readmissions.

What follow-up can and cannot do

Teams working to reduce readmissions pay attention to wound follow-up for a practical reason. A wound can easily leave the hospital without a clear owner. The surgeon assumes primary care has it, primary care assumes home health has it, and home health is waiting for orders.

No follow-up arrangement can promise that a patient stays out of the hospital, and some returns are the right decision. What follow-up does is support continuity: someone is assessing the wound, orders and supplies are in place, and a change reaches a clinician who can act on it. This guide is general education, not clinical or compliance advice.

Where wound plans break after discharge

When you trace a wound-related return backward, the same gaps keep appearing:

• No named clinician is responsible for the wound.
• The follow-up appointment is at a clinic the patient cannot reach.
• The patient goes home with two days of dressings and no order for more.
• Discharge instructions, home health orders and facility admission orders describe different treatments.
• Equipment such as a negative pressure device or a pressure-relieving mattress is not in place on arrival.
• Wound records never reach the receiving nurse or clinician.

Patients who deserve a closer look before they leave

This is a prompt for your own judgment, not a scoring tool. Look twice at the plan when a patient has:

• A wound that is new or got worse during the stay
• A pressure injury and limited mobility, going home to a family caregiver
• A diabetic foot wound, an open surgical wound or negative pressure therapy
• A history of missed appointments or transportation problems
• A destination facility where no wound clinician visits

A discharge-side checklist

1. Name the owner. Write on the discharge instructions who will assess the wound next and how that visit is being arranged.
2. Send the wound record. Location, type, measurements, date of last assessment and current treatment orders. The discharge to home wound handoff guide has a fuller list.
3. Bridge the supplies. Send enough dressings to last until the first order arrives, and confirm who is ordering more.
4. Confirm who changes the dressing. Make sure that person has been shown how and is able to do it.
5. Reconcile the orders. The discharge summary, the home health referral and any transfer orders should describe the same treatment.
6. Arrange follow-up the patient can reach. If travel is the barrier, ask about wound care after hospital discharge from a clinician who comes to the patient.
7. Connect primary care. Blood sugar, swelling and new medications need an owner too. See follow-up care after hospital discharge.
8. Refer early. Call when the wound is identified, not on the morning the patient leaves.

The receiving side: the first days

In a facility. Complete the skin assessment on admission and compare it with what the hospital sent. Resolve any mismatch with the attending physician that shift. If your building has facility wound rounds, add the resident to the next list and flag the admission as new.

At home. Home health staff should confirm at the start of care which clinician is signing wound orders, and report any conflict between the discharge paperwork and the agency’s orders.

In both settings, put three checks on the calendar for the first two weeks. Has the first wound visit happened? Did the supplies arrive? Is whoever changes the dressing managing it? Families can use the first two weeks after the hospital.

What patients and families should report

Teach these before discharge and repeat them at the first visit. Report to the treating clinician:

• Redness, warmth or swelling that is spreading
• More drainage, a change in its color or a new odor
• Increasing pain or a fever
• A wound that has opened or looks larger

Call 911 for heavy bleeding that will not stop, chest pain, trouble breathing, fainting or sudden confusion.

How Gateway supports continuity

Gateway arranges wound visits from partner clinicians where the patient lives after discharge, in homes and facilities across Greater St. Louis and the Metro East, and coordinates records, orders, supplies and communication among the care team. See continuity of care and the page for hospitals and discharge planners.

Call 314-325-0126, fax 314-786-7966 or send a referral request. The form takes contact details only. Availability is confirmed by location, and we do not promise visit timing or outcomes. The treating clinician makes every clinical decision, including when a patient needs a higher level of care.

Common questions

Related pages

• Wound care after hospital discharge
• Hospitals and discharge planners
• Continuity of care
• Transitional care after discharge
• Discharge to home wound handoff
• Refer a patient
• Wound rounds preparation checklist
• Weekly wound documentation tips