BAndrew Applewhite’s patient had HIV and diabetes. She needed dialysis, but she had used up all the days in her Medicare stay and was discharged from a Texas skilled nursing facility.

That the patient was blind and unable to get to a week’s worth of dialysis appointments — or see the pressure ulcer she had to care for at home — hadn’t been accounted for in her discharge plan. 

So when she ended up back in the hospital after taking on too much fluid, her Stage IV, osteomyeletic wound also needed additional treatment.

“People are being discharged with wounds that they either aren’t comfortable with or aren’t prepared to handle,” says Applewhite, M.D., CWSP, head of Baylor University Medical Center’s Comprehensive Wound Center. “It really is facility-dependent. Some are very good at arranging follow-up, and some are not.”

Skilled nursing facilities are increasingly tasked with treating residents whose wounds outlast the condition that landed them in long-term care. That’s a tough combination in a reimbursement environment in which 30-day hospital readmissions net SNFs a 2% penalty.

Cathy Milne, MSN, APRN, CWOCN-AP of Connecticut Clinical Nursing Associates, says 30% of readmitted patients have a wound, a correlation skilled nursing providers need to take seriously. Though a wound might not drive a resident back to the hospital, its presence should be seen as a red flag.

Ideally, the facility will ensure a caregiver, home health provider, community physician or wound clinic steps into the void after discharge. But even then, a win for skilled nursing requires foresight, careful coordination and sustained focus.

“Picking good partners (in) home health, making follow-up calls to those who have discharged, providing caregivers contact information for someone at the facility they can ask questions to and walking through an emergency/urgency plan if the wound isn’t healing as anticipated are all ways to impact the final outcome, which is wound healing,” said Amy Stewart, RN, vice president of curriculum development for the American Association of Nurse Assessment Coordination.

Support systems

There is no one-size-fits-all approach to post-discharge care.

Factors such as access to services, severity and complexity of the wound and available equipment must shape the plan, Applewhite and a team of wound specialists wrote in 2018 panel recommendations governing outpatient use of negative pressure wound therapy. While NPWT has transformed wound care, it requires close monitoring when used at home. Patients should be able to flip a switch and turn on the vacuum, but Applewhite has treated patients whose family members disconnected the units due to their sound. A home visit would reveal that more quickly than self-reporting, he says.

Applewhite recommends SNFs partner with home care agencies that have wound care-certified staff or coordinate care through a wound clinic. Milne would like to see regional consortiums help SNFs select home care organizations with good care records.

Those choices should be made before discharge. Applewhite also suggests providers order patients a starter pack of dressings, or they connect the patient with a durable medical equipment company for home delivery.

“All these things need to be coordinated, and it can take a small army to get it done,” he says.

Still, wound stability — rather than complete healing — is becoming a more common discharge goal.

“New dressings stay in place for longer periods of time and are just peel-and-stick — making it easier to prevent wounds once someone has left or for family members to maintain the treatment when they go home,” notes Jayne Warwick, a former home care wound specialist and now marketing director at PointClickCare. 

But true skin health also requires adherence to nutrition and hydration plans, whether that means avoiding sugar, adding protein or monitoring skin for further breakdown.  

Skilled nursing providers also have to consider their resident’s goals post-discharge.

“If the patient is at the end of their life, they may not want aggressive wound care but just want wound care that can keep them comfortable and help them preserve their dignity,” notes Armi Earlam, lead of the wound, ostomy and continence department at Colorado’s Lutheran Medical Center. Dressings that contain drainage and control odor may be enough.

With maintenance goals, providers must ensure charges understand enough about care to avoid trouble. To ensure compliance, Earlam suggests the teach-back method, or what Stewart calls “return demonstration.”

Before discharge, nursing staff should demonstrate the steps involved in care — from changing dressings to positioning — and then ask the home caregiver (or patient) to perform those steps.

“If the caregiver doesn’t feel comfortable, then there is a greater risk the wound care either won’t be done, won’t be done as often as ordered, or done as instructed,” Stewart says.

If discharging to a wound clinic or a community physicians, Earlam notes, patients also should be told new doctors may prescribe alternative treatments.

If referring to homecare, providers can ask the assigned nurse to attend a pre-discharge conference on needed supplies and in possible protocol changes. It’s something Milne has begged for, and she sometimes prevails.

Want a resident to stick with a home treatment plan? Show them the progress they’ve already made, whether in photos or charts, Applewhite says. Next, schedule HIPAA-compliant calls, emails or texts to the patients’ home to remind them of the importance of routine care.

Trusted Partners

Some SNFs are establishing their own home care lines to exert control over post-discharge care. 

Continuity can be a bonus, according to Quality Surgical Management. The Florida company has its own medical staff and the ability to provide the same care in a SNF and at a patient’s home, but officials say their role typically ends when a patient is discharged because of payment issues.

What’s worse, says CEO/CMO Steven Magilen, M.D., is that some SNFs discharge residents without asking treating specialists to weigh in on after-care.

COO Dave Lotz adds that wound care specialists likely save costs with home visits by identifying social determinants like unsanitary conditions or poor diet that could contribute to a readmit.

Such companies would welcome more coordination.

“How to have it happen is difficult,” Magilen acknowledges. “Everybody is looking at the elephant from their own blind point of view.” 

A role for tech

QSM says it would like referring providers to have access to its wound treatment notes and vice versa. The company is moving its Qsmart app to the cloud, making it more accessible to frontline staff and administrators interpreting data.

Such resources create opportunities to see each patient’s wound care struggles.

Swift Medical is developing tools that help hospitals, SNFs and home health providers streamline transfers and avoid redundant treatments  — potentially saving money while improving outcomes. The idea is to tie wound care history to a patient.

“Sometimes, it’s as simple as using a wound care app, or the EMRs talking to each other even if there’s not full integration, just at least exchanging data,” says Amy Cassata, RN, WCC, vice president of clinical operations. “You can see what worked before, what didn’t work and track other things, like, is the patient compliant? Do I need to get a dietitian involved?”

Any customer with a log-in can track their patient through a shared patient code and dashboard. Home care may track treatment, while skilled nursing providers can check for rehospitalization patterns among various partners.

Home care staff may focus on charting wounds, but remote, specialized wound nurses can routinely review that data and prioritize who they need to see, Cassata says.

So far, Swift’s platforms are clinician-facing, but the future may bring platforms that put imaging and data-reporting in the hands of a wound patient.

Apps like PointClickCare’s Skin and Wound app can “improve the accuracy of measurement of healing overtime and therefore the ability to track healing,” Warwick says. 

“When they are included in the record, those pictures can be overlaid and you can actually see how the edges of the wound change over time by scrolling through them,” she explains.

Telemedicine may make efforts easier. In an April article in Wounds Research, editorial board member Laura Bolton, Ph.D., examined two studies of at-home wound management. Researchers found a smartphone app and Skype were valuable tools for the management of diabetic foot ulcers, pressure ulcers and some leg ulcers.

“Telemedicine can protect patients from difficult transfers and journeys to clinical care centers that interrupt daily living and increase the potential for injury or breakdown,” Bolton writes.

Even as skilled nursing improves relationships with home care, Applewhite says most “aren’t quite there yet” when it comes to sharing platforms or data.

It’s unclear to wound care doctors exactly how skilled nursing providers are tracking the success of post-discharge wound care plans or their partners’ ability to manage treatment or costs.

The expectation is that more will do so over time. Milne says identifying successful partners ultimately would be good for the bottom line and residents.

Milne is embracing tech innovation as a partner in a start-up that lets providers share formularies online. 

Home health agencies “have to accept that we need to use technology more,” Milne says. “If we all work together, we can improve communication, and that improves care.” n