Connect Care Manual - Inter-Facility Transfers

Inter-facility Transfers

Patient transfers from one facility to another can occur for a number of reasons. Care may need to escalate (e.g., transfer to a tertiary care facility) or shift to an alternate level of care (e.g., transfer to a rehabilitation or long-term care facility).

Computers do not transfer patients. It is always important to establish shared understanding between sending and receiving teams about what is about to happen and who bears what responsibility. A "Discharge Transfer Gateway" can help prescribers to use that shared understanding when selecting an appropriate navigator to organize review, action and documentation tasks.

Discharge Transfer Gateway

A "Discharge Transfer Gateway" is available as a tab (or More menu option) within all charts opened to an inpatient encounter. A variant of the Gateway also appears for emergency department encounters in the "Disposition" tab.

There are three Gateway sections, each directing prescribers to the appropriate navigator(s) specific to the particular discharge or transfer destination(s):

Discharge from Current Facility
- - - To Home or Community Services
      - For patients who are being discharged from hospital, to home or to community care. Note that this includes sending to a Supportive Living (SL) or Designated Supportive Living (DSL) facility, as such a destination facility often functions like a patient's home.
        Manual: Discharge Navigator
    - Discharge as Deceased
      - Patients who pass away within or on arrival to a hospital encounter are "discharged", with unique documentation requirements facilitated by the Discharge as Deceased navigator.
        Manual: Discharge as Deceased
Transfer within Current Facility
- - - Patients shifting from one hospital service's (specialty) to another experience an Intra-facility Transfer. Such within-facility transfers may involve moving to a different ward or bed (e.g., transfer from Family Medicine to Critical Care). However, a physical move is not required (e.g., transfer from Family Medicine to General Internal Medicine on the same ward).
      - Note: A long-term care/Continuing Care centre is considered a separate facility even when located in the same building as an inpatient unit.
        Manual: Within-facility (Intra-facility) Transfer Navigator
Send to Another Facility
- - - Leave of Absence (LOA) – For patients who will be temporarily away from the unit, but will be returning (e.g., patient on a pass).
      - Manual: Patient Movement - LOA
    - Inter-facility Transfer (IFT) – For patients who will be discharged and admitted to another facility, either to a facility with or without Connect Care pharmacy services. Specific subsections address requirements specific to transfers out-of-province or within-province to acute or Continuing Care facilities.
      - Details on IFT workflows are below.

Leave or Transfer?

A transfer occurs when a patient moves to a different facility and is not expected to return.
A leave of absence occurs when the patient is expected to return. (For more information, see the Leave of Absence section of this Manual.)

When to Involve RAAPID?

The RAAPID service manages all consultation requests within Connect Care. It should be used for transfers to a higher or lower level of care (including repatriations), and for transfers to emergency care. For more information, including workflows specific to emergency and specialties, see the RAAPID Services section of this Manual.

Admission or Transfer?

The receiving sites may or may not use Connect Care as the record of care.

A transfer received from a non-Connect Care site (e.g., out-of-province) functions like a Direct Admission, while a transfer received from a Connect Care site is handled within Connect Care.
A transfer sent from a Connect Care site is handled differently, depending upon whether the destination site is on Connect Care or not, as detailed below.

Connect Care or non-Connect Care Facility?

Connect Care has been fully deployed throughout Alberta, but sometimes there may be uncertainty about which facilities and sites are using Connect Care as their record of care.

In general, acute care facilities within Alberta use Connect Care. Continuing care facilities may or may not use Connect Care as the record of care and may or may not use Connect Care for pharmacy services. Inter-facility transfers (IFT) to continuing care facilities with internal (Connect Care) pharmacy services follow default IFT workflows where medication needs are communicated through signed-and-held orders (no medication reconciliation required). IFTs to facilities with external pharmacy services require discharge medications to be handled with prescription orders, more akin to discharge to home workflows where medication reconciliation is needed.

The following online look-up tool can be used when prescribers are unsure about whether a destination facility is using Connect Care or not:

Database: Connect Care Sites

Ideally, inpatient teams will have identified a target transfer facility in advance of entering a discharge order. When this is done, the IFT navigator automatically adjusts workflow guides to match needs for facilities that have Connect Care but no internal pharmacy services.

Inter-facility Transfers from Non-Connect Care Facilities

Inter-facility transfers (IFTs) from sites where Connect Care is not the record of care (e.g., out-of-province) follow their usual processes. This involves a RAAPID call requesting consultation and possible transfer to a different level of care. If a transfer is approved, the sending site prepares transfer documents and transport orders in their legacy systems (e.g., paper).

Inter-facility Transfers from Connect Care Facilities

All IFTs from a site where Connect Care is the record of care are managed with one of the "Inter-facility Transfer" navigators, selected by using the "Discharge Transfer Gateway" navigator. The gateway provides simple instructions and prompts to help prescribers follow the correct workflow. It is important to note different paths from the gateway according to whether the patient is going to a Connect Care site or to a non-Connect Care site.

Notes: Every transfer to a Continuing Care site (e.g., Long-Term Care [LTC], Designated Supportive Living, post-acute, hospice) is an IFT. A LTC/Continuing Care centre is considered a separate facility even when located in the same building as an inpatient unit.

Inter-facility Transfer from Connect Care to Alberta Facility using Connect Care (click to expand/collapse)

Use the Discharge Transfer Gateway and select the navigator link for "Acute Care Facility within Alberta"
Follow the navigator instructions and all review-action-documentation steps in order from top to bottom to ensure that the needed medication review, problem reconciliation and order reconciliation is done.
- - - - Use the problem list reconciliation step to tidy up any inpatient problems that have been resolved and to confirm the principle problem at the time of transfer (be sure to click "Mark as Reviewed" when done).
      - Use the "Transfer Details" section to confirm, add or edit information about where the patient is going and who will be assuming responsibility for ongoing care (section text is "interactive"... click to edit).
      - Clean up all inpatient orders, especially any recurring lab or test orders, so that remaining orders reflect what is likely needed at the destination.
      - Pay particular attention to medication orders, comparing these to home medications, to ensure that what the patient is on reflects what the patient will continue to take at the new facility (be sure to click "Mark as Reviewed" when done). PRN orders (with "For EMS" added as the order reason) can be provided for medications or manipulations required in transit.
Ensure that a discharge summary is prepared and reflects the completed problem, orders and medication lists.
Confirm that the "IFT Orders" have generated an appropriate discharge order (with "Transfer to another facility" as disposition) before signing.

Since the receiving facility is on Connect Care, there is no need for printed documentation. All the IFT navigator work will be visible to and used by the receiving facility.

Inter-facility Transfer from Connect Care to Alberta Facility NOT using Connect Care (click to expand/collapse)

Virtually all Alberta acute care facilities use Connect Care. A number of continuing care facilities do not use Connect Care. The main difference for transfers to sites not using Connect Care is that continuing inpatient orders and other advice needs to be communicated within printed or faxed transfer documents. The discharge process approximates what is done when discharging a patient home.

Use the Discharge Transfer Gateway and select the navigator link for "Continuing Care Facility within Alberta, NOT Connect Care". This will open a "Non Connect Care IFT" navigator.
Follow the navigator steps from top to bottom to ensure that the needed medication review, problem reconciliation and order reconciliation is done.
- - Use the problem list reconciliation step to tidy up any inpatient problems that have been resolved and to confirm the principle problem at the time of transfer (be sure to click "Mark as Reviewed" when done).
  - Use the "Transfer Details" section to confirm, add or edit information about where the patient is going and who will be assuming responsibility for ongoing care (section text is "interactive"... click to edit).
  - Clean up all inpatient orders, especially any recurring lab or test orders, so that remaining orders reflect what is likely needed at the destination.
  - Select the "Discharge Orders" navigator section to open an orders activity that facilitates medication reconciliation, generation of any needed new prescriptions (printing can be suppresed if needed) and confirming or creating orders for consultation or follow-up. Receiving facilities may request completion of this step at least a day before transfer, allowing time for medications to be lined up by pharmacy services (internal or external).
Ensure that a discharge summary is prepared and reflects the reviewed problem, orders and medication lists.
Confirm that the "IFT Orders" have generated an appropriate discharge order (with "Transfer to another facility" as disposition) before signing.

Since the receiving facility is not on Connect Care, instructions, transfer orders and possibly medication prescriptions must be printed. Clinical support staff generate printed documentation that will accompany the patient.

Inter-facility Transfer from Connect Care to Out-of-Province Facility (click to expand/collapse)

Transfers to facilities outside of Alberta resemble within-province transfers to facilities that do not use Connect Care. Orders and other care advice needs to be communicated as part of printed or faxed transfer documents.

- Use the Discharge Transfer Gateway and select the navigator link for "Acute Care Facility outside of Alberta". This will open an "Out of Province Transfer" navigator.
- Follow the navigator steps from top to bottom to ensure that the needed medication review, problem reconciliation and order reconciliation is done.
  1. 1. Use the problem list reconciliation step to tidy up any inpatient problems that have been resolved and to confirm the principle problem at the time of transfer (be sure to click "Mark as Reviewed" when done).
    2. Use the "Transfer Details" section to confirm, add or edit information about where the patient is going and who will be assuming responsibility for ongoing care (section text is "interactive"... click to edit).
    3. Clean up all inpatient orders, especially any recurring lab or test orders, so that remaining orders reflect what is likely needed at the destination.
    4. Select the "Reorder Home Medications" navigator section to open an orders activity that facilitates medication reconciliation, generation of any needed new prescriptions and confirming or creating orders for consultation or follow-up. Receiving facilities may request completion of this step at least a day before transfer, allowing time for medications to be lined up by pharmacy services (internal or external).
    5. Use the "IFT Orders Note" step in the navigator to review, edit and sign the automatically generated "Interfacility Transfer Order Reconciliation Report".
- Ensure that a discharge summary is prepared and reflects the reviewed problem, orders and medication lists.
- Confirm that the "IFT Orders" have generated an appropriate discharge order (with "Transfer to another facility" as disposition) before signing.

Inter-facility Transfer from Connect Care ED to Connect Care Admitting Facility (click to expand/collapse)

Some AHS facilities have an emergency department (ED) service but no inpatient beds. A partnered (usually rural) facility has inpatient beds and the ED prescriber may be admitting a patient from the first ED to the receiving second facility. Indeed, the prescriber may have cross-covering responsibilities at the second site.

Such workflows should be handled like an Interfacility Transfer from one Connect Care site to another for direct admit.

Tip: Interfacility Transfer from ED for Direct Admit

Inter-facility Transfer from Connect Care to Continuing Care Facility (click to expand/collapse)

Inter-facility transfer of a patient to a Continuing Care facility (e.g., Long-Term Care, Designated Supportive Living, post-acute, hospice) has some slight differences from other IFTs. This is because Continuing Care facilities require different information at different times than other acute care sites. Every transfer to LTC/Continuing Care is an IFT, even if the LTC/Continuing Care is located in the same building.

The IFT processes described above apply, according to whether the continuing care site is on Connect Care or not. There are some additional considerations.

Initiation - When a decision is made by the responsible physician and inpatient care team that a patient requires and is appropriate for continuing care, two orders should be entered:
- - - - Order "Inpatient Consult to Discharge Planning/Transition Services" - this order ensures that placement protocols are initiated and patients join waitlists in the appropriate order for expected destination facilities.
      - Order "Initiate ALC" (alternate level of care) - this order should be placed whenever the current facility has completed its patient care function and care can and should continue at an alternate facility. This order is important because it also sets a "virtual discharge date" used when calculating the patient's adjusted length of stay.
Preparation - Once a facility, bed and reception date have been set, the sending physician should attend to problem, medication and order reconciliation. The appropriate IFT navigator (Continuing Care with or without Connect Care) should be used to line up the needed documentation and advance notice of required medications and other patient needs.
Transfer - The sending physician completes the final order reconciliation, plus discharge order, and updates any transfer documentation following the steps described above.
Note: When sending a patient to a Connect Care LTC facility, the IFT navigator will present the appropriate tools based on whether the LTC has an internal or external (contracted) pharmacy service.
- - - - Support: Workflow Updates for Transferring Patients to Continuing Care Facilities

For more information on IFT to Continuing Care workflows, see the below resources: