Today's health care climate is trending to shortened hospital stays and seamless delivery of care from admission to an acute care facility through discharge to self care. Patients with wound, ostomy, or continence issues can present siginificant discharge planning challenges to the WOCN and care coordinator charged with implementing a safe discharge plan. The problems for discharge disposition may include: severity of debility, high visit frequency, high cost and low availability of supplies, unsuitable location and condition of residence, lack of support persons, and limited or no payer resource for care. Often the patient presents a combination of all these issues and this compounds the problem of safe and adequate discharge care. Home care agencies are feeling the financial impact of the Prospective Payment System and are setting limitations on some patient care referrals. Industry wide there is an increase in the number of home health agencies who are refusing twice a day visits or patients with costly supply needs. Where does the WOCN go when trying to obtain post hospital or post skilled facility care for patients? How can resources be developed so that a consistent reliable source of care is available with just a call? This presentation will explain a model used for collaboration between a home care agency and inpatient institutions in the largest city in Maine. WOCN's attending this session will be able to integrate the following into their practice: 1. A working knowledge of the basics of home care operations. 2. How to develop collaborative relationships with home care providers. 3. The ability to explain home care services to patients who will be receiving these services. and 4. Identify patients, early in their stay, who will present more challenging discharge planning needs.