Why a Case Manager Needs to Add a Wound Care Referral on Top of Home Health

A home health order sends a nurse to the house. It does not send a wound plan with that person.

For a patient battling a chronic wound, adding a wound care referral puts a wound specialist in that home to evaluate the wound, write the orders the nurse follows, and reassess when the wound stalls. As a result, it greatly improves the chances the wound heals and keeps the patient out of the hospital.

At Wound Care Specialists, a multi-state, physician-led wound care practice that makes house calls, we understand the stress case managers face, and we know a referral only helps you if it comes back with an answer. That is why we commit to confirming every referral within 24 hours, so you know we have it and whether we can take the patient before you move on to the next discharge.

The rest of this article covers what happens after you hit send, because that is the question case managers actually ask us.

What happens to a complex wound on home health alone?

A home health nurse carries out the orders she is given. If the discharging physician ordered a silver dressing, for example, that is what the wound gets, visit after visit, whether or not it is still the right dressing.

Few agencies have a wound-certified nurse on staff, and the ones who do are often newly certified. Rarely is anyone asking why the wound is not healing, and no one is ordering the supplies the wound actually needs, so the family buys dressings out of pocket or the wound goes without.

It's also not uncommon for a home health agency to decline a wound that looks difficult or a patient whose insurance does not fit, which leaves a case manager back at square one on discharge day.

The common result is the one you already know: The patient is back in your ER inside 30 days with the same wound, typically larger.

That readmission lands on the hospital, the home health agency, and the facility all at once. Keeping the patient home is better for the patient, especially oncology and immunocompromised patients who should not be sitting in a waiting room, and it is better for everyone's numbers.

Kat Freeman, an area director for Wound Care Specialists in Virginia, puts it this way to home health nurses: "We are not trying to replace you. You are important to the treatment plan. We need you to partner with us, or this patient is not going to heal as quickly."

What happens in the first 24 to 48 hours after I send the referral?

You send the referral by fax or through our referral page. Some hospitals also reach us through Careport or Epic. (Ask your WCS area director what works at your building.)

Our intake team confirms two things back to you: that we received the referral, and whether we can take the patient. We strive to get that confirmation to you within 24 hours. If the answer is yes, we move to scheduling. If we need something before we can say yes, usually insurance information or wound documentation, the same message tells you exactly what is missing. If we cannot take the patient, we tell you that too, so you are not waiting on a referral that is going nowhere.

Once we accept, our scheduler calls the patient or family and sets the first visit. You get the date. The wound specialist sees the patient at home, and your home health agency gets a physician plan and orders to work from.

That is the whole sequence. Nothing in it requires you to call us back.

Why does the confirmation matter more than the visit date?

Freeman, our area director in coastal Virginia, spends most of her week with hospital case managers. She says they are not asking how fast we can be in the home. They know a physician practice takes a day or two to get there. What they need is to know the referral landed.

One case manager told her: "I need to know if you got it or not, and can you help. Once I know that, have at it. I trust you."

Case managers right now are past capacity. Patients are boarding in ER hallways and pre-op bays, and flu and COVID might be moving through the community. When a referral sits with no acknowledgement, the case manager assumes it went nowhere and sends the patient to the hospital's own wound clinic. A patient who can barely get out of the house now has a standing appointment across town.

Slow confirmation is an industry-wide problem, and we learned how much it costs as we grew. A referral that waits two days for a yes is a referral that gets redirected. We have the right people in intake and scheduling now, and the 24-hour response is the standard we hold ourselves to.

What should I send so the yes comes faster?

The more complete the referral, the faster we confirm.

Send the face sheet with insurance, the most recent wound notes (two weeks is the minimum; 30 days is better), and a current medication list.

If a home health agency is already assigned, include the agency name so we coordinate from the first visit instead of the third.

Is Wound Care Specialists a home health agency?

No. Please do not list us as one in Epic.

We are a physician-led wound care practice that makes house calls. We do not replace the home health order. We sit alongside it, the way a cardiologist sits alongside the nurse managing a heart failure patient at home.

The agency handles the visits and the dressing changes. We handle the diagnosis, the plan, and the reassessment when the plan is not working.

When is Wound Care Specialists not the right referral?

If the patient needs surgical debridement in the operating room, inpatient IV antibiotics, or vascular intervention first, send them there and refer to us for the follow-up.

If the patient lives outside our coverage area, or we do not accept their insurance in that state, we tell you in the same confirmation message so you can move on quickly.

What should I do next?

Keep the home health order. Add Wound Care Specialists to it. Fax the referral (704 833-8442) or use our referral page, and expect to hear from us within 24 hours.