Wound Patient Discharge Planning: Taking the Interdisciplinary Approach

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By Paula Erwin-Toth MSN, RN, CWOCN, CNS

Part 2 in a series discussing the challenges and opportunities in patient/family education
For Part 1, Click Here

Last month you met Mr. Gillan a (fictional) 72 year old man with venous insufficiency. He presents with a venous ulcer on his left lower leg. He has several co-morbid conditions including hypertension, cataracts, and osteoarthritis which includes his hands. His primary caregiver is his 74 year old wife who suffers from diabetes and mild dementia. They do not have any family living nearby. He is being discharged to his home with a primary wound dressing and compression wraps. His discharge instructions include requests for Home Care nursing and follow up with vascular medicine and a pedorthist.

Let’s think about planning for his discharge. Clearly he needs an interdisciplinary approach for his discharge planning. This planning is not only essential for his care and safety but are included in the Hospital Accreditation Standards as defined by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) (Sections National Patient Safety Goals; Standards, Rationales, Elements of Performance, and Scoring).

JCAHO standards clearly describe the obligation health care providers have to meet Mr. Gillan’s diverse needs. Every institution has their own protocol for coordinating patient care and services to enable a smooth transition to discharge. In a case as complex as Mr. Gillan is it may seem difficult to know where to begin. Patient care conferences are an ideal venue to pull together the key players in providing Mr. Gillan’s care. These conferences may be coordinated by the Case Manager or Social Worker.

Case Managers and Social Workers are key individuals in helping to coordinate a smooth transition from acute care to the next setting where his care will continue.

An obvious place to begin is interviewing Mr. Gillan. All too often we as caregivers think we know what a patient needs and what resources he has at his disposal but fail to ask the person most concerned-the patient! Mr. Gillan has been very active in his church and has a wonderful network of willing and responsible helpers. They have recently hired a ‘Parish nurse” who can help coordinate transportation to doctors’ appointments and meal delivery. Although the nurse does not do ‘hands on care’ she can marshal and organize volunteers. In fact, they have arranged supervision for Mrs. Gillan while Mr. Gillan has been hospitalized. Skilled nursing care in the home will be a must to monitor his wound and provide dressing changes. A home health aid, physical therapy and dietician may also be needed. Social workers can help Mr. and Mrs. Gillan plan for future needs such as adult day care, assisted living and perhaps eventually long-term care.

About The Author
Paula Erwin-Toth has over 30 years of experience in wound, ostomy and continence care. She is a well-known author, lecturer and patient advocate who is dedicated to improving the care of people with wounds, ostomies and incontinence in the US and abroad.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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