Challenges of transitioning wound patients through the continuum of care – Q&A

November 2016



How much do chronic wounds account for hospital readmissions?

Let’s start by looking at readmissions overall. Discharges to home health agencies comprise about 11% of releases from the acute care setting, while discharges to post-acute care (PAC) make up about 22%, according to the Agency for Healthcare Research and Quality (AHRQ).1 In addition, one in five patients admitted to a skilled nursing facility (SNF) are readmitted to the hospital within 30 days, according to a technical report by the Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AoA) 2.  These readmissions cost, on average, $10,352 per hospitalization, for an annual total of $4.34 billion2.

These data points were the basis of a study examining the causes behind 30-day hospital readmissions at a rural skilled nursing and rehabilitation center in southeast Michigan. The study showed that cellulitis, a serious bacterial skin infection that can spread rapidly to other parts of the body if left untreated, was the third-highest DRG (diagnosis-related group) for 30-day hospital readmission — second only to congestive heart failure and S/P limb Sx (post-thrombotic syndrome.)3

Why is this happening?

We can attribute the high rate of readmissions — chronic wound patients, in particular — to a litany of issues, which are in one way or another hindering care transitions. It is why CMS’s Office of Clinical Standards, through its Quality Improvement Organization (QIO) Program’s 9th Scope of Work4, was focused on care transitions. This work includes coordinating care and promoting seamless transitions across settings, reducing unnecessary readmissions and defining evidence-based interventions.

What we know about the continuum of care for chronic wound patients is that they typically start from home, are admitted to the hospital when their condition becomes acute, then discharged to a long-term care or skilled nursing facility before returning home for follow-up or ongoing care by a home health professional with oversight by their provider(s). Along the way, they may make stops back and forth to a wound clinic. Or, they may see their primary care physician, who will admit them to the hospital. This journey is paved with a myriad of challenges and obstacles that can compromise patient care and healing and, ultimately, result in readmission.

What kinds of challenges or obstacles are chronic wound patients encountering along the continuum?

These can be anything as fundamental as access to transportation to and from the physician’s office or wound clinic to the disparity between follow-up care (dressing changes, primarily) recommended or prescribed to patients upon discharge from the hospital and what insurers will actually cover. Many of these dressings are available over the counter; however, they can be costly and unaffordable for some patients. Patients who can afford them, assuming they and/or a family member or caregiver has transportation to a retailer, are faced with so many product choices that they often become confused or overwhelmed by what to purchase. As a result, they may leave empty-handed, compromising care and outcomes.

How is this affecting providers and clinicians?

On the provider side, we see dilemmas in wound care delivery. Each care setting has different incentives, regulations, reimbursement and payment systems, as well as conflicting strategies and interests. Oftentimes, this results in “gaming” the system, which ultimately is not in the best interest of the patient and fails to improve patient outcomes.

Tied to this are challenges wound care nurses face trying to provide care to patients day to day. Let’s start with practice patterns: It’s not uncommon for wound care nurses to encounter “we always do it this way here” attitudes in various care settings, even when these “ways” are not considered best practice.  Also, cost coverage of wound care dressings varies across the care continuum. Medicare reimburses the acute care hospital, long-term acute care hospital (LTCH), and the skilled nursing facility for all routine, ancillary and capital costs, including surgical dressings, under the Medicare Severity Diagnosis Related Group (MS-DRG), long-term care hospital (LTCH-DRG), and resource utilization group (RUG) prospective payment system rates for Medicare Part A stays, respectively. At home, Medicare Part B, an elective benefit, will typically cover 80% of the costs for surgical dressings and the patient may be obligated to cover the rest if they don’t have a supplemental plan. Coverage by Medicaid and private insurers vary widely by state and plan respectively, and in some cases may leave the patient with a substantial out-of-pocket balance. 

In the meantime, clinicians are finding themselves working in silos, where the exchange of information from care setting to care setting is out of balance for numerous reasons. Often, there is a lack of complete information about a patient upon transfer, including the absence of goals for recovery and/or plan of care. A patient’s health history is oftentimes “lost” or incomplete. Follow-up diagnostic testing is spotty, leaving an inaccurate, incomplete or insufficient picture of a patient’s condition at transition.  In the meantime, coordination with clinical specialists from care setting to care setting is generally poor, also resulting in unnecessary visits.

With elderly patients, who represent a large population of chronic wound patients, comes additional complexity. They typically require medication reconciliation. And, they are not familiar with or they are intimidated by electronic personal health record systems, failing to maintain and manage their health information as a result. The opportunity and potential for better outcomes is higher when family members or close friends are involved in a patient’s care, however, this isn’t always the case. 

Can you provide an example of this dilemma?

Yes. Let’s look at an elderly, obese male patient with a diabetic foot ulcer. While still at home, this patient is likely seeing a podiatrist and receiving care at a wound clinic. This same patient is equipped with a vascular blood glucose monitor and, because he has neuropathy, has been casted to offload pressure that has caused and/or is exacerbating his condition. As the wound begins to heal, he will transition to shoewear dressings to prevent injury or re-injury of the tissue, and he’ll be prescribed an antibiotic if osteomyelitis is present. All of this requires a physician work-up, patient education and follow-up to ensure a positive outcome.

Unfortunately, this patient’s infection has spread, and he’s had to be admitted to the hospital for surgery and bedrest. He is placed on intravenous antibiotics and may be seen by an orthotist and nutritionist. Also, his vascular blood glucose device must be evaluated. Upon discharge, he is transferred to a skilled nursing and rehab facility for further bedrest and physical therapy. He’ll continue to receive antibiotics, dressing changes and negative pressure wound therapy, plus follow-up on his blood glucose and orthotics. He requires transportation upon discharge.

At home, this patient requires wound care dressings that enable him to ambulate, care coordination between the wound clinic and primary care physician, and continued blood glucose monitoring. To ensure his safety and a positive outcome and prevent readmission, patient education is essential, particularly as he offloads to shoewear.

What can be done to improve transitions of care and patient outcomes?

One of the most effective and immediate ways to reduce 30-day readmissions is by “activating” patients as consumers and essential partners in their own care. In looking at other chronic disease models such as congestive heart failure for best practices, we know that the addition of a one-hour, nurse educator-delivered teaching session at the time of hospital discharge resulted in improved clinical outcomes, increased self-care measure adherence, and reduced cost of care in patients with systolic heart failure.5 Realizing that patients aren’t always in the listening mindset when they’re getting ready to leave the hospital, it’s also good practice to send them home with supportive information or teaching aids that are highly visual. These are particularly beneficial to patients at a low reading level.

We also know that patients have a better chance of recovery and are less likely to have to be readmitted when we engage a family member to serve as transition coach and we firmly establish the primary care physician as “home base.”

Finally, with the shift to a consumer-driven model, the same brand and type of products being used in the clinical setting are now available over the counter. It’s our responsibility to give patients and their family members or caregivers the knowledge, skills and confidence they need to make informed choices when selecting products necessary to their care and healing — in the same way we teach them how to make healthy lifestyle choices. Medical products suppliers are giving us the additional time to do this by offering services to support and facilitate the transition of wound care patients upon discharge. These services range from paperwork verification to payor authorization.

1 Tien, W. An All-Payer View of Hospital Discharge to Postacute Care, 2013. Available at:

2 Ezeike,C. Skilled Nursing Facility Readmission Measure (SNFRM) NQF #2510: All-Cause Risk-Standardized Readmission Measure. Available at:

3 Muscat S. Reducing Hospital’s 30 day Readmissions from Skilled Nursing and Rehabilitation Level of Care March 15, 2013. Available at:

4 Center for Medicare and Medicaid Services, 2008. Available at:

5 Todd M. Koelling, MD; Monica L. Johnson, RN;  Robert J. Cody, MD;  Keith D. Aaronson, MD, MS. Discharge Education Improves Clinical Outcomes in Patients With Chronic Heart Failure. American Heart Association. 2005; 111: 179-185

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