Inter-Facility Transfers

Patient transfers from one facility to another can occur for a number of reasons. Care may need to be escalated (e.g., transfer to a tertiary care facility) or shifted 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 facility or site and is not expected to return. Either or both of the sending and receiving sites may use Connect Care as the record of care. A transfer from a non-Connect Care site functions like a Direct Admission. A transfer from a Connect Care site is handled differently depending upon whether the destination is on Connect Care or not.

Computers do not transfer patients. In all cases, it is important to have established 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 RAPPID call for direct interaction with a potentially receiving consultant. In the case of transfers to a lower level of care, the less urgent consultation is best triggered by a "RAPPID Repatriation" order entered into Connect Care.

Inter-Facility Transfer to Connect Care Sites

An "Interfacility Transfer" navigator is available as a tab within the "Discharge" activity when a patient's chart is opened to an inpatient encounter. This explains tasks that must be completed and should be used.

  • 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 both the completed problem, orders and medication reconciliation.

  • 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 Interfacility Transfer navigator work will be visible to and used by the receiving facility.

Inter-Facility Transfer to non-Connect Care Sites

An "Interfacility Transfer to Non-Connect Care Site" navigator is available as a tab within the "Discharge" activity when a patient's chart is opened to an inpatient encounter. 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 a printed/faxed transfer report.

  • 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).

  • Note the "Suggested Orders" step where advice to the receiving team is documented. Be sure to use the ".activeord" SmartText to pull in results of the Orders reconciliation/clean-up performed earlier. Right-click on this and select "Make selected text editable" to allow any indicated further edits. Additional narrative instructions can be provided at the bottom of the note before signing off with ".me".

  • 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. It may serve better to delete the medications section of the discharge summary template and use the ".crtmeds" SmartLink to pull in a simple list of currently ordered medications.

  • Be sure to enter a "Discharge" order to complete the process.

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.

Inter-Facility Transfer to Continuing Care

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 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.

    • Order "Initiate ALS" (alternate level of care) - this order should be place 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 Inter-facility Navigator (within 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

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