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.

Infographic: Patient Movement Support for Admitted Patients

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 ED and specialties, see the RAAPID Services section of this Manual.

Admission or Transfer?

Either or both of 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 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. The following two resources can be referred to for a Connect Care facility list, to help clinicians determine which transfer workflows to use.

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. 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.

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

Interfacility Transfer from Connect Care to Connect Care Site (click to expand/collapse)

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. There 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 Site (click to expand/collapse)

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

There are two options within the navigator:

- Interfacility Transfer Orders (Non Connect Care): To be used with sites that do not use Connect Care.
- IFT to Out of Province Acute Care: To be used with any site outside of Alberta.

Interfacility Transfer Orders (Non Connect Care)

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 "Discharge Orders" link has generated an appropriate discharge order before signing.

IFT to Out of Province Acute Care

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 from Connect Care ED to Connect Care Admitting Site (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

Interfacility Transfer from Connect Care to Continuing Care Site (click to expand/collapse)

Interfacility 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 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 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 (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.
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 Facility

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

More Information

Resources

- Infographic: Patient Movement Support for Admitted Patients
- Guide: Patient Movement