Demonstrating Positive Outcomes through a Continuum of Care Approach

Statement of Problem:  With shorter stays and stresses associated with hospitalization and surgery, it is not surprising that ostomates experience physical and psychological difficulties upon discharge from the hospital.  Even if referred to home care, many ostomy patients initially lack basic skills and knowledge which can impact their quality of life.  Effective rehabilitation requires support beyond short-term needs after discharge^1,2,3. 

Overview:  Recent changes in health care have resulted in fragmentation of care.  Shorter hospital stays, fewer outpatient stoma clinics, reimbursement issues, fewer WOC nurses in home care, and decreases in pre-op visits are contributing factors.  Collaboration and referral to defined programs can help to insure continuity of care, improve outcomes, and enhance patient satisfaction. WOC nurses have experienced this first hand.  Implementation of a defined continuity of care program resulted in changes in clinical practice in both acute and home care settings.  Patients not only received supplies, but also ongoing support, ostomy education, answers to simple questions, assistance with suppliers, and insurance knowledge.  This type of program reinforces the education started by the WOC nurse and provides patients with needed information beyond clinical expertise. 

In addition to experiential results, a random survey was completed evaluating the experiences of patients (n=347) who had the benefit of an organized continuity of care program. The data was significant demonstrating that planned follow-up and assistance after discharge was highly valued, and aided in the adjustment to having a stoma.  Eighty-seven percent said the program performed a valuable service in adjusting to life with a stoma, and 98 percent stated they were glad their nurse enrolled them in the program.

Conclusion:  Data supports that patients benefit when collaboration is a part of their plan following ostomy surgery.  This comes from a strong support from the WOC nurse, family, and an organized continuity of care program.