continuity of care, cross-setting collaboration, wounds



  1. Thomas, Maria E. BSN, MS, RN


Objective: With guidance from Health Services Advisory Group, the Arizona Medicare Quality Improvement Organization, a Prescott, Arizona, workgroup consisting of a hospital, nursing home, and 2 home health agencies have come together to improve continuity of care as related to pressure ulcer prevention and treatment.


Methods: Weekly, then monthly, meetings were held to develop recommendations for practice standardization, a treatment grid for easy reference, an educational module with posttests, and standardized physicians' orders, which were developed and disseminated to the local provider community.


Results: More than 200 staff members were educated at Yavapai Regional Medical Center (YRMC), local skilled nursing facilities, and home health agencies. In addition, new employees and nursing students are now educated on the Providers' Coordination of Care Educational Module at YRMC. The Module has been placed on the hospital's Web site and offered free to all interested parties.


Implications for case management: With pressure being mounted by Centers for Medicare & Medicaid Services, the Office of the Inspector General (OIG), and the general public, the role of the case manager (in all practice settings) will increasingly become more crucial. Through development of a network of local venues of care, the case manager can facilitate care transitions throughout the healthcare system with the goal of improved outcomes for the patient regardless of setting. Providing the right care, in the right setting to improve patient care, can only benefit our aging and declining populations.


Conclusions: Cross-setting work will become more essential as the Centers for Medicare & Medicaid Services goal of pay-for-performance is realized across all care settings. As a national priority, pressure ulcer prevention and treatment needs to be embraced by all settings. It serves the patient, as well as the healthcare providers, to improve care regardless of setting or competition. Positive results can be accomplished if the best interests of the patient are kept at the forefront. To this end, obstacles of competition and individual facility possessiveness must be overcome to achieve the desired results. Having the right mix of professionals will enhance the results. The lessons learned here can be used in any across-the-settings initiative.