The Role of Homecare WOC Nurse in Preventing Rehospitalization

The health care landscape is changing.  The Affodable Care Act has prompted CMS to take on the challenge  of developing a new and sustainable health care system.(1)  The

goal of preventing rehospitalizations is forefront of this new focus. The homecare WOC nurse is in a unique position to make a difference in working toward this goal.    

The WOC nurses in our homecare agency and the Quality Assurance staff looked at the readmission rate for the WOC patients in order to decide on which diagnosis to focus our

efforts on preventing rehospitalizations.  Over 33% of homecare patients have wounds.(2) Preventing rehospitalization for patients with surgical wounds and lower extremity

ulcers are the two areas chosen to focus our efforts.  The WOC nurse team realized the way to improve our outcomes is to provide patients with more in depth teaching tools.  Using 

evidence based data to formulate the teaching tools ensured the best possible treatment modalities for the patients.  Presenting patients with interesting and useful information

are key components of helping them to improve their health and prevent hospitalization.              

Working together with the Quality Assurance staff to measure the effects of the efforts will provide the data necessary to modify our tools on an ongoing basis.

While the WOC nurses cannot do this alone it is important for all the homecare staff to work together to achieve the goal of preventing rehospitalization. 

 The patients with these conditions need to be identified early so preventative care can implemented as soon as patients are taken onto service by the

homecare agency.  Working togther with the Quality Assurance staff to measure the effects of our efforts will provide the data necessary to modify our tools on an ongoing basis.

This in turn leading the WOC nurse team to undertake future endeavors to prevent rehospitalization for other patients with wound, ostomy and continence diagnosises.