Avoiding Hospital Re-admission: Innovative Strategies for Effective Transition of Complex Wound Ostomy Continence Patients

Since 1977, the average length of stay for patients age 65 and older has decreased from 16.4 to 5.6 days (2004). While this average length of stay continues to be longer than that of other groups, the care needs of patients in this population are greater and functional ability is less, making this the most likely population requiring skilled nursing care following hospital discharge. Recent literature reveals great successes in assuring a safe and effective transition between health care environments for patients with congestive heart failure, Diabetes Mellitus, or are taking high risk medications. No research exists regarding the use of similar approaches among complex wound, ostomy, and continence patients. Failure to adequately plan for the patient’s discharge may lead to decreased adherence to treatment protocols, increase in re-admission rates, decreased ability for patients or staff to recognize complications, and increased psychological distress for the patient. The WOC nurse can ease these transitions for patients by: explaining the patients care to the patient and family, communicating treatment plans directly to nursing staff at the receiving facility, and conducting hands on training in complex cases (especially for facilities/agencies without a WOC specialty nurse). This poster describes the approaches of one Midwestern health system where the hospital WOC nurse provides hands on, patient specific education to home care nurses, hospice nurses, and skilled nursing facility staff. This interdisciplinary and interfacility approach to care of the complex WOC patient can reduce hospital readmission rates, length of stay in the skilled nursing facility (if applicable), and improve patient satisfaction and quality of outcomes. Three success stories will be shared.