Where Wounds Really Heal: Why Post-Acute Care Deserves a More Dynamic Wound Care Conversation And Measurement
This year, I attended the SAWC Spring Conference for the first time.
As someone who has spent decades in post-acute care, long-term care, rehab, quality, and wound care, I walked in excited to learn, observe, and absorb everything I could from one of the most respected wound care conferences in the country. And I did. The science was impressive. The research was deep. The innovation was exciting. The conversations around cellular tissue products, advanced therapies, diagnostics, procedures, imaging, technology, and emerging wound care solutions reflected just how vast and sophisticated the wound care field has become.
But as I sat through sessions and walked the exhibit hall, I also felt a growing tension.
Much of what I saw was rooted in research labs, outpatient wound centers, surgical practices, hospital-based programs, and acute care environments. Much of the innovation appeared designed for settings with access to advanced diagnostics, procedural reimbursement, specialty workflows, and high-cost technologies that are often more naturally aligned with hospital and outpatient infrastructures. And yet, so many geriatric wounds do not live their full healing journey in those settings.
They come back to us. They navigate the rest of their journey through post-acute care.
They come to the skilled nursing facility. They come to inpatient rehab centers. They come to assisted living. They come home with home health. They come back in the hands of family caregivers, CNAs, nurses, therapists, dietitians, wound physicians, nurse practitioners, medical directors, MDS coordinators, infection preventionists, and interdisciplinary teams trying to manage the wound in real time, every day.
That is where the disconnect became clear to me.
The wound may be discovered in acute care. It may be debrided in a clinic. It may be evaluated by a specialist. It may be dressed with the newest product or supported by the latest technology. But for many older adults, the healing is achieved or the battle is lost, in post-acute care. And that is the conversation we are not having loudly enough or maybe I am part of the problem for not raising my voice sooner.
So to strengthen my argument, I went data diving. National wound care statistics confirm the magnitude of this problem, but even those numbers tell an incomplete story. A 2025 update on the burden of chronic wounds describes chronic wounds as affecting approximately one in six Medicare beneficiaries, or about 10.5 million people, with an estimated $22.5 billion in annual Medicare cost. Ouch! That statistic is powerful. It tells us wound care is not a small specialty issue. It is a major Medicare issue, a geriatric issue, a chronic disease issue, and a health system issue. But even that number does not tell us where the wound actually lives day to day.
A Medicare claims analysis estimated total Medicare spending for wounds between $28.1 billion and $96.8 billion, depending on methodology, and found a higher trend toward costs associated with outpatient wound care compared with inpatient care. That is important data, but it also reflects where services are billed, procedures are coded, products are reimbursed, and claims are captured.
It does not fully reflect the daily work of turning, offloading, feeding, toileting, monitoring, educating, reassessing, escalating, and encouraging healing in post-acute and long-term care settings. (An argument for another day as to why post-acute care reimbursement (Medicare and Medicaid) based on this level of care should NOT be up for cuts but continuously up for improvements). That is the problem with black-and-white wound statistics. They show cost, prevalence, utilization, and setting of service, but they do not always show burden, and they certainly do not tell the patient story.
Geriatric wound care is not less complex because it happens outside the hospital. In many ways, it is more complex. The resident with a pressure injury likely also has dementia, diabetes, vascular compromise, malnutrition, incontinence, contractures, pain, limited mobility, depression, poor intake, polypharmacy, fragile skin, edema, infection risk, and inconsistent tolerance or adherence to the plan of care. The wound is not isolated from the person. The wound is living inside the reality of aging, chronic disease, function, cognition, behavior, reimbursement limits, family expectations, regulatory pressure, and quality measurement. Then add all this amazing new research I consumed at SAWC about everyone’s skin biome is unique and powerful in the trajectory of injury and healing…oh, wait those conversations aren’t really happening in post-acute care nor is it in standard of care.
Nursing home data makes this complexity even more visible, while still not telling the full story. CDC/NCHS reported that 11% of U.S. nursing home residents had a pressure ulcer(injury) in the data studied, and among residents with Stage 2 or higher pressure ulcer(injury)s, only 35% received special wound care by trained professionals or staff. A more recent systematic review of pressure injuries among older people reported a pooled nursing-home-acquired pressure injury rate of 8.5%, with Stage I and Stage II injuries most commonly reported. Those numbers matter and really aren’t surprising. But again, they do not tell the full post-acute story. And I will shout this from the highest mountains the rest of my career.
They do not tell whether the resident arrived from the hospital already nutritionally depleted, immobile, incontinent, septic, edematous, cognitively impaired, or vascularly compromised. They do not tell whether the wound was present on admission, unavoidable, worsening despite appropriate intervention, improving slowly, or being managed under comfort-focused goals. They do not tell whether the resident refuses repositioning, removes offloading devices, sits in a wheelchair for long periods, has pain with movement, or cannot tolerate aggressive interventions.
They also do not tell how quickly the post-acute wound story begins. AHRQ’s patient safety text notes studies in skilled nursing facilities where 80% of pressure ulcer(injury)s developed within two weeks of admission and 96% developed within three weeks. That is a striking statistic, but even it can be misunderstood if read too simply. It may look like a post-acute failure point, when in reality those first two to three weeks are often when the resident is arriving at their most fragile point: immediately after hospitalization, surgery, infection, immobility, functional decline, weight loss, medication changes, or a major medical event. Let me whip out my magic healing wand. I’m still looking for one of those by the way.
These stats do not tell you they already had two stage IVs that have been present for 18 months and three newly community acquired Pressure Injuries in the last month before admitting to a post-acute setting. The stats do not tell us of those 80-96% who acquired pressure injuries in two to three weeks, how many were expected to develop more and how many are unavoidable. Dare I even mention organ failure, yes skin organ failure?
I would also add that this is where administrative burden vs. quality patient assessment collide. In retrospect, we often find that pressure injuries are admitted at a higher stage (III) vs. the acute care’s staging (II). Why is this common? In my experience stage II and III are the most commonly mis-staged level in my decades of chart reviews and wound care. Post-acute care not having time nor feeling empowered to challenge what acute care says, nor clinical depth to discern when a wound is mis-staged before they even see it for the first time, creates a data error train wreck and significant mismeasurement right out of the gate. This is why the post-acute wound story cannot be told by incidence alone.
Don’t hear me wrong. Post-acute care is not without resources, expertise, or structure. Many organizations have vendor agreements with wound specialists and honestly, this could be a good or not so good thing. To quickly elaborate on this point, I have observed wound groups do the minimum while degrading the confidence and ownership by the staff that care for these patients every day. Okay-back on track.
Many post-acute care providers invested in their own wound experts. All have interdisciplinary teams to address skin and wound care with some combination of disciplines including therapy partners, dietary support, medical directors, nurse practitioners, wound rounds, risk meetings, QAPI systems, and clinical leaders who understand the seriousness of skin and wound care. Personally, I have spent years driving success in skin and wound care programs in LTC through stabilization by reducing variables and maximizing formularies, growing expert access, supplying training and education, and driving smart dynamic efficient documentation practices.
The issue is not simply that post-acute care lacks access or knowledge. The issue is that post-acute wound healing requires time, strategy, coordination, consistency, and clinical flexibility-with time (defined as time to healing/closure or advanced care planning) being the most important element. These elements do not always fit neatly into the current way wound outcomes are publicly measured or regulated.
This is the heart of my concern.
In post-acute care, wounds are often managed through a narrow lens out of necessity: stage it, measure it, document it, treat it, report it, monitor it, avoid facility-acquired status, and protect the quality measure. Those things matter. Accurate staging matters. Documentation matters. Prevention matters. Survey readiness matters. Public accountability matters. But wound healing is not a straight line nor is it one size fits all.
Yet the quality measure asks a much narrower question: did the resident have a pressure ulcer(injury) during a defined time period? That question has value, but it cannot possibly tell the full wound story and I argue nor does it have value in defining or measuring quality post-acute care settings.
Post-acute care has lived with skin-related quality measures for years. Pressure ulcer(injury)s have been part of post-acute care quality measurement, public reporting, Five-Star ratings, survey focus, and reimbursement conversations for a long time. These measures were designed to create visibility, accountability, and comparison. They help signal that skin integrity matters. But what do they really tell the public? I would argue pretty much nothing as they are structured now. The measure may count the wound, but it does not tell the wound story. That is the limitation of using a narrow outcome measure to represent a complex clinical reality.
This does not mean skin quality measures should go away. They keep skin integrity visible. They push facilities to pay attention. They encourage prevention, monitoring, documentation, and accountability. But they are incomplete if they become the primary public interpretation of wound care quality.
What we need is not less accountability. We need better and informative accountability. We need measurement that recognizes both prevention and complexity (not just risk adjustment or short-stay vs. long-stay). Regulatory surveys are an effective way to determine whether a post-acute care skin and wound care system responded dynamically, clinically, and appropriately. So is that not enough to determine a quality post-acute care setting?
Outside of this, quality measurement has to be more reflective of the complexity of wound development and wound healing potential. This is where post-acute care deserves more respect in the national wound care conversation, research, and quality measurement arena.
I’ll end with this question that takes me back to the top:
Why is so much wound care innovation concentrated in settings where the wound is seen episodically, while the settings where the wound is lived with daily are measured by narrow outcomes that cannot capture the complexity of healing? I have some thoughts about that…but what do you think?
Post-acute care cannot remain the afterthought of wound care. It is where the long game is played. It is where prevention becomes practice. It is where the wound plan meets real life. It is where the resident’s body tells the truth. It is where healing is achieved or where the battle is lost.
#WhereWoundsReallyHeal #PostAcuteCare #WoundCare #GeriatricWoundCare #SkinIntegrity #PressureInjuryPrevention #LongTermCare #SkilledNursing #RehabCare #NursingHomeQuality #HealthcareQuality #QualityMeasures #QAPI #InterdisciplinaryCare #WoundHealing #SeniorCare #ClinicalLeadership #PACMatters #HealthcareInnovation #PatientStory #ResidentCenteredCare #WoundCareInnovation #CareContinuum #HealthcareAdvocacy #SkinAndWoundCare #SNFQuality #AgingCare #NursingLeadership #TherapyMatters #CNAImpact #AdvantageYOUHCS #AHCA #McKnightsLTCNews #PAWSIC #CMS5Star
Footnotes / References
Chandan K. Sen, “Human Wound and Its Burden: Updated 2025 Compendium of Estimates,” Advances in Wound Care, 2025. This source reports that chronic wounds affect approximately one in six Medicare beneficiaries, or about 10.5 million people, with estimated annual Medicare costs of $22.5 billion.
Susan R. Nussbaum et al., “An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds,” Value in Health, 2018. This Medicare claims analysis estimated Medicare wound-care costs between $28.1 billion and $96.8 billion, depending on methodology, and found a higher trend toward costs associated with outpatient wound care compared with inpatient care.
Eunice Park-Lee and Christine Caffrey, “Pressure Ulcers Among Nursing Home Residents: United States, 2004,” National Center for Health Statistics Data Brief No. 14, February 2009. This CDC/NCHS report found that approximately 159,000 nursing home residents, or 11%, had pressure ulcers of any stage, and that 35% of residents with Stage 2 or higher pressure ulcers received special wound care.
R.D.U.P. Sugathapala et al., “Prevalence and Incidence of Pressure Injuries Among Older People Living in Nursing Homes: A Systematic Review and Meta-Analysis,” International Journal of Nursing Studies, 2023. This review reported a pooled nursing-home-acquired pressure injury rate of 8.5%, with Stage I and Stage II pressure injuries most commonly reported.
Courtney H. Lyder, “Pressure Ulcers: A Patient Safety Issue,” in Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Agency for Healthcare Research and Quality, 2008. This AHRQ/NCBI text cites studies by Bergstrom and Braden finding that in a skilled nursing facility, 80% of pressure ulcers developed within two weeks of admission and 96% developed within three weeks of admission.
Agency for Healthcare Research and Quality, “On-Time Pressure Ulcer Prevention.” This AHRQ long-term care resource reports that median annual nursing home pressure ulcer prevalence was 7.5% in 2009, with associated costs of $3.3 billion annually. This was not directly quoted in the draft, but it may be useful if you want another post-acute-specific cost statistic.
Zhanlian Chen et al., “Accuracy of Pressure Ulcer Events in US Nursing Home Ratings,” JAMA Network Open, 2022. This source is useful if you want to support your argument that pressure ulcer quality data and public reporting may not fully or accurately tell the wound story. The study found incomplete reporting of pressure ulcer events among long-stay nursing home residents.
