When a wound leaves the hospital with you
A discharge plan usually covers medications, appointments and activity limits. The wound needs its own next step. Gateway arranges wound care after hospital discharge in St. Louis and the Metro East, so a partner clinician picks up the hospital’s wound plan in the home or facility where the person is going.
Who post-discharge wound follow-up helps
The service fits people who leave the hospital, for home or for a facility, with a wound that still needs a clinician’s attention:
- A surgical wound that is open, draining or slow to settle
- A pressure injury that formed or got worse during the stay
- A foot or leg ulcer that was treated in the hospital and has not closed
- A wound that was drained or surgically cleaned and now needs regular dressing changes
- A wound managed with a device, such as a wound VAC
What the treating clinician may do after discharge
The partner clinician who sees the wound makes the clinical decisions. Depending on the wound and the hospital’s instructions, that clinician may:
- Read the discharge summary and wound instructions, then examine the wound and the skin around it
- Measure and describe the wound so later visits have a baseline
- Continue the hospital’s dressing orders or write new ones
- Look for infection, pressure, swelling or poor blood flow that could slow healing
- Order supplies and set how often the wound should be seen
- Contact the surgeon or hospital team if something needs their attention before the planned follow-up
Gateway does not assess wounds or change orders. Our part is the coordination around the visit.
How Gateway arranges the handoff
- The request. A discharge planner sends a referral, or a patient or family member calls us. Families do not need a referral to ask.
- Records. We ask for the discharge summary, wound instructions, the operative note if there was surgery, and the medication list. The discharge planner wound referral checklist shows what helps most.
- Setting and availability. We confirm where the person will be and whether a partner clinician visits that location and care setting. Coverage questions are reviewed with the treating provider.
- After the visit. We route orders, supply requests and updates to home health, facility nursing, primary care and the family contact.
Follow-up at home or in a facility
The first days at home are often the hardest. Home health may not have started, supplies may be short, and a family member may be changing a dressing for the first time. When an agency is involved, our page on wound care alongside home health explains who does what. The family discharge checklist lists the papers and phone numbers to keep.
In skilled nursing, rehabilitation, assisted living or memory care, the partner clinician sees the resident on site and leaves orders for the nursing team. If the resident later moves home, we help the wound plan move too, as part of our continuity of care work.
Keeping primary care and the surgeon informed
A hospital stay often changes medications, blood sugar control, diet or mobility, and each of those affects healing. A primary care clinician is the one who pulls them together. Gateway sends wound updates to that clinician and can arrange follow-up care after hospital discharge with a primary care partner for people who have no clinician able to see them where they live.
Wound follow-up does not replace the surgeon’s post-operative appointment. Keep that visit and bring the wound notes.
Changes to report after you get home
Tell the treating clinician or home health nurse about any of these:
- Redness, warmth or swelling that spreads from the wound
- More drainage than before, or drainage that turns thick, cloudy or foul smelling
- Pain that is getting worse instead of better
- Fever or chills
- Wound edges pulling apart, or stitches or staples coming loose
Our guide to the signs of wound infection explains more. Gateway is not an emergency service. Call 911 for bleeding that will not stop with firm pressure, a surgical wound that suddenly opens wide, chest pain, trouble breathing or sudden confusion.
How to start
Patients and families can request care or call 314-325-0126. The web form asks for a name and phone number only, so please save medical details for the call.
Hospital teams can refer a patient or fax referral documents to 314-786-7966. Visit availability is confirmed by location and care setting.
Common questions
Can wound follow-up be requested before the discharge date?
Yes, and that is usually the better time. A request made while the person is still in the hospital lets us gather records and confirm whether a partner clinician visits the home or facility they are going to. We cannot promise a visit date.
Do I still need my surgeon’s follow-up appointment?
Yes. The surgeon stays responsible for the surgical plan, and that appointment is usually where decisions about stitches, staples, drains and activity limits are made. Wound visits arranged through Gateway add regular checks between those appointments. If the treating clinician sees a change the surgeon should know about, the surgeon’s office is contacted.
The hospital already ordered home health. Is this the same thing?
No, and the two often work together. Home health nurses carry out the plan between visits, including dressing changes, teaching and monitoring. A wound care clinician assesses the wound, writes or updates the orders and decides when a specialist is needed. Tell us which agency the hospital chose so visits can be lined up with its nurses.
Will my plan pay for wound visits after a hospital stay?
That depends on your plan, the treating provider and the care you need. You can ask us about Medicare, Medicare Advantage, Medicaid and commercial plans, and the treating provider’s office reviews benefits before care is arranged. Ask what the visits, supplies and any equipment would cost you, and whether your plan requires prior authorization.
Related pages
General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.