Interfacility 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).

A transfer occurs when a patient moves to a different site and is not expected to return. A leave of absence occurs when the patient is expected to return.

Computers do not transfer patients. In all cases, it is important to establish shared understanding between sending and receiving teams about what is about to happen and who bears what responsibility. In the case of transfers to a higher level of care, consultation is usually initiated with a RAAPID call to a potentially receiving consultant. In the case of transfers to a lower level of care, the consultation is usually initiated by a "RAAPID Repatriation" order entered into Connect Care. All emergency department to emergency department transfers must involve RAAPID. If in doubt, call RAAPID.

Either or both the sending and receiving sites may use Connect Care as the record of care. A transfer received from a non-Connect Care site 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 a bit differently, depending upon whether the destination site is on Connect Care or not.

Interfacility Transfers from Non-Connect Care Sites

Interfacility transfers (IFTs) from sites where Connect Care is not the record of care follow their usual processes. In most cases, this involves a RAAPID call requesting consultation and possible transfer to a higher level of care. If a transfer is approved, the sending site prepares transfer documents and transport orders in their legacy systems (e.g., paper).

Interfacility Transfers from Connect Care Sites

All IFTs from a site where Connect Care is the record of care are managed with an "Interfacility Transfer" navigator, found as a single tab within the "Discharge" activity available when a patient's chart is opened to an inpatient encounter. The navigator contains instructions. It is important to note different paths within the navigator according to whether the patient is going to a Connect Care site or a non-Connect Care site.

Interfacility Transfer from Connect Care to Connect Care Sites

  • Follow the navigator steps from top to bottom to ensure that the needed medication review, problem reconciliation and order reconciliation is done.

    • 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).

    • 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).

  • Ensure that a discharge summary is prepared and reflects the completed problem, orders and medication reconciliations.

  • Confirm that the "IFT Orders" have generated an appropriate discharge order 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. Their are some minor workflow differences if transfers are initiated from the emergency department of one site (e.g., Wave 2 site) for receipt at a higher level of care (e.g., Wave 1 site).

Interfacility Transfer from Connect Care to non-Connect Care Sites

The main difference for transfers to sites not yet using Connect Care is that orders and other care advice needs to be communicated as part of printed or faxed transfer documentation.

  • Use the "Manage Orders" step to go to the Orders tab, to ensure that all current orders are as intended and any superfluous orders are cleaned up or simplified (e.g., vitals orders).

  • 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).

  • 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).

  • Be sure to place a "Discharge Patient" order.

  • Use the "IFT Orders Reconciliation Note" step in the navigator to review, edit and sign the automatically generated "Interfacility Transfer Order Reconciliation Report".

  • Complete a discharge summary, using an approved SmartText template (e.g., "AHS Core IP Discharge Summary") that pulls in the reconciled problem list and other key information.

Since the receiving facility is not on Connect Care, instructions and transfer orders must be printed. Clinical support staff use a variant of the Interfacility Transfer navigator to generate printed documentation that will accompany the patient. There are some minor differences if transfers are initiated from emergency at a Connect Care site.

Interfacility Transfer to from Connect Care to Continuing Care Site

Continuing care includes nursing home, long-term care and extended care facilities. The processes described above apply, according to whether the continuing care site is on Connect Care. 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.

    • Order "Initiate ALS" (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 (within the "Discharge" activity) 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.

  • Tip: Transfer to Continuing Care

Leave of Absence for Procedure

Transfers for patients going temporarily from a Connect Care site to a different site, with expectation of return, are managed with a "Leave of Absence" navigator. This is found as a single tab within the "Discharge" activity available when a patient's chart is opened to an inpatient encounter. The navigator contains instructions.

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