1. Indication for hospitalization

2. Primary care

• Identify/confirm primary care physician (PCP)
• Contact/notify PCP of patient admission, diagnosis, predicted discharge date
• Schedule PCP follow-up within 7-14 days of discharge

3. Medication safety

• Reconcile home and admission medications
• Teach proper use of discharge medications and their relation to prior home medications
• Reconcile discharge, prior-home, and hospital medications

4. Identify and communicate wound care-related supplies and durable medical equipment (DME) to accepting organization

• Ask nursing and physical therapy what they think the patient will need at the accepting organization
• Negative pressure wound therapy:
• Communicate brand that the patient has been using
• Check if orders have been placed for specific equipment or therapy requirements after discharge and what the expected date of arrival of equipment is
• Pressure redistribution devices
• Hospital bed with low air loss mattress
• Dressing change:
• Frequency of dressing change
• Type of dressing change
• Compression bandages (if needed)
• Bariatric supplies (if applicable)
• Ostomy equipment including manufacturer name, product number and number of ostomy supplies
• Offloading devices (e.g. cast shoes, crow boots)

5. Follow-up plans

• Post-discharge follow-up phone call within 72 hours for high-risk patients (high LACE index score [Length of stay, Acuity on admission, Comorbidity, and Emergency department visits])
• Arrange outpatient studies (e.g., lab, radiology) if needed
• Arrange specialty clinic follow-up if needed (e.g. wound clinic and/or wound specialist)

6. Home-health referral

• Home-health agency shares information about patient's preexisting community services
• Engage home-health agencies
• Schedule post-discharge home health (if needed)

7. Transition to post-acute care (e.g. skilled nursing facility)

• Ensure care plan can be followed at the receiving facility
  
• For patients with pressure ulcers/injuries, ensure adequate pressure redistribution surface and staff is available to implement bundled preventative care as soon as patient arrives 

8. Communication with outpatient providers:

• Provide discharge summary, medication and durable medical equipment (DME) reconciliation information, and inpatient attending contact information to patient, PCP, community pharmacy, DME supplier, and caregiver
• See tool "Provider Wound Communication"

9. Patient education

• Use teach-back method
• See topic "Patient Education in Wound Care and Hyperbaric Oxygen Therapy"
• Find patient education handouts for patients with chronic wounds
• Explain relation between new medications and diagnosis
• Explain discharge summary
• Explain expected home course, including anticipated or possible symptoms and circumstances and when patient should contact his or her physician