By Melinda Young
Chronic wounds account for many patient admissions and readmissions every year. Wound readmissions are costly — and often preventable. Wound ulcer readmissions due to diabetes cost more than $250 million a year, and pressure ulcer-related readmissions cost more than $11 billion, research shows.1
One reason patients with wounds often return to the hospital is the lack of adequate care transitions and follow-up in the community.
“If you have a chronic illness — say, diabetes — we would not send you home without teaching you how to use your insulin and setting you up for follow-up. But if you have a wound, we may not do anything,” says Holly Kirkland-Kyhn, PhD, FNP, CWCN, FAANP, an assistant clinical professor at the University of California, Davis Betty Irene Moore School of Nursing.
Inadequately preparing patients and caregivers for wound care at home can be costly. Pressure ulcers can cost tens of thousands of dollars a year, per patient, Kirkland-Kyhn says. Each patient with this wound needs costly supplies and a special hospital bed. Nurses must turn them every two hours.
“At any given day in the hospital, we had 40 patients who had pressure ulcers,” Kirkland-Kyhn recalls. “We wanted to know where people were getting pressure ulcers. I thought it might be nursing homes, so we collected data over a year for every patient admitted.”
Kirkland-Kyhn and her colleague were surprised by the results. Less than 2% of pressure ulcers occurred in the hospital. Of the 98% that occurred in the community, few occurred in nursing homes.2
“They’re all coming from home, and it makes sense,” Kirkland-Kyhn says. “They have no nursing care at home. They probably refuse to be turned by their caregivers.” The fact that so many of these patients are repeatedly hospitalized shows that patient and caregiver education and care transition support should be a priority.
Home health nurses need additional education on treating patients with deep wounds, including pressure sores, says Ron Ordona, DNP, FNP-BC, GS-C, WCC, study co-author and clinical director of Senior Care Clinic House Calls and administrator and health services director of Care Home By RNs Congregate Living Health Facility, both in Sacramento. “Education plays a big role in this because we need to educate each other on how to manage these types of conditions more effectively,” Ordona adds. “We are working on a group of teaching videos that will help the educational component of care for nurses in community-based care. The videos will explain different kinds of wounds, so nurses don’t treat a vascular wound as if it’s a pressure wound.”
In an ideal world, there would be more education and a warm handoff to home health because home health nurses often do not know how to handle wound care, Kirkland-Kyhn says. “The best thing is to have that last [case] note available for everyone to see,” she adds.
When patients transition to the community, their charts often are not available for the next provider to see. This is a communication gap that needs to be fixed. Otherwise, it is a repeated cycle of wound patients being hospitalized, receiving care and beginning to heal, then heading home — only to be sent back to the emergency department by their primary care provider because the wound worsened at home.
“Transition of care is challenging, and everyone will agree,” Ordona says. “It’s expensive for a health system for multivisit patients to come back and forth to the emergency room or hospital.”
Even when patients are discharged to a nursing home, information about their wound may be sparse or entirely absent. “We had people discharged to a nursing home, and there’s not one mention of their stage four pressure wound,” Kirkland-Kyhn recalls. “I was appalled. They get a bare bones of a chart.”
There should be a warm handoff with patients sent to the nursing home with photos of the wound and a note about their wound and the care they received. The information should be in the electronic medical record and sent to the next provider, Kirkland-Kyhn explains.
Administrative and technological obstacles can block this from happening. This is why case managers and clinicians need to use practical workarounds, teaching patients and caregivers how to treat the wounds and handing them information to share with their next provider.
For example, Kirkland-Kyhn found a workable solution. Providers ask patients for permission to photograph their wounds on the patients’ own phones. Then, they show patients the wounds and explain how to change the dressings. Patients take the photos and information they learned to their home health nurse or primary care provider.
“We tell them to show their nurse or doctor what the wound looked like and what we used to dress it,” Kirkland-Kyhn explains. “This gives patients more ownership. We also could videotape ostomy bag changes.”
This method works better than giving patients a link to wound care videos online, she notes. “Patients might say, ‘That doesn’t look like my wound. With these phone photos, we say, ‘This is your wound,’” Kirkland-Kyhn says. “They feel better if you’re walking them through it and they’re doing their bag or dressing changes on their own. They own it themselves.”
In one case, Kirkland-Kyhn used the phone photos (with the patient’s permission) to show providers at a Federally Qualified Health Center (FQHC). The providers could follow up with the patient, who did not have a primary care provider or insurance to cover those visits.
“Another patient was homeless and got into a sword fight, injuring his arm,” Kirkland-Kyhn recalls. “We had the wound dressed, and we sent him on a bus to be seen by the FQHC.”
The patient’s wound photos went with him, and the clinic providers saw him twice a week until the wound healed. “The warm handoff helps,” she says.
As the person on the receiving end of the warm handoff, Ordona found communication from the hospital to be challenging at times. “We have achieved no intercompatibility with health records within the community,” he says. “When we get patients from the hospital, our electronic health records do not communicate, so it’s usually through paper — and with paper, there’s always a chance you miss an important document.”
Federal laws and regulations also make electronic communication from hospitals to community providers more difficult. “We have to protect the patient’s privacy,” Ordona says. “Someday soon, there may be a way to breach through that. But in the meantime, this warm handoff program with pictures on patients’ phones seems to be working.”
With the patients’ phones containing wound pictures, HIPAA concerns are addressed because it is the patient’s information to share as they like.
“In the general sense of the transition of care — whether from a higher level of acute care down to community-based care or vice versa — the warm handoff would be the highest standard where I can get a call from the provider in the hospital, saying, ‘I’m sending you this and this, and this is how it looks,’” Ordona explains.
The warm handoff does not happen frequently enough because all healthcare professionals are busy, and patients fall through the cracks, Ordona adds. “That’s why we’re pushing for at least one model of transition of care that we’re trying out, even if it’s not perfect,” he says.
REFERENCES
- Oota SR, Rahman N, Mohammed SS, et al. Wound and episode level readmission risk or weeks to readmit: Why do patients get readmitted? How long does it take for a patient to get readmitted? Assoc Comp Mach 2020:1-7. https://arxiv.org/pdf/2010.027...
- Kirkland-Kyhn H, Ordona RB. Multi-visit patients (MVP) and transitions of care (TOC): Evidence-based project on readmissions and continuation of care. UC Davis Health. 2024. https://ehob.com/media/2-28-ni...
Inadequately preparing patients and caregivers for wound care at home can be costly. Pressure ulcers can cost tens of thousands of dollars a year, per patient. Each patient with this wound needs costly supplies and a special hospital bed. Nurses must turn them every two hours.
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