White Paper
March 1, 2010

March 2010

I. Introduction

The purpose of this white paper is to recognize and emphasize the importance of efficient patient-centered processes for transferring patients from the acute-care hospital (ACH) to skilled nursing facility/nursing facility (SNF/NF) and from SNF/NF to ACH, including the emergency department (ED). Rather than duplicate the practical material already available in AMDA’s recently published Clinical Practice Guidelines (CPG) Transitions of Care in the Long-Term Care Continuum and Acute Change of Condition in the Long-Term Care Setting, documents and tools from the National Transitions of Care Coalition (NTOCC), and others, this paper aims to highlight critical factors in the care transition process and to specify key features of a successful care transition process. We will refer to some specific documents and tools currently available, but these are by no means exhaustive, and the interested reader is directed to the additional resources found in the Summary of Available Tools section.

Transitions between silos of care like ACHs and SNF/NFs are well known as a frequent nidus for medical errors that cause harm to patients. Moreover, it is well established that transferring a patient from a familiar environment (e.g., the SNF/NF where s/he resides) to a new, unfamiliar, and potentially bewildering location like an emergency room can cause severe and sometimes permanent decompensation and lead to medical errors. So while we aim to discuss methods of optimizing transfers between these settings, another important goal should be to reduce the incidence of inappropriate transfers, particularly those resulting in unnecessary rehospitalizations—a topic of great concern in the current health care climate. While a detailed discussion of this topic is beyond the scope of this paper, it is mentioned both for its importance and its relevance to this paper—since more efficient, safer processes for initial ACH-to-SNF/NF transfers are likely to reduce the need for rehospitalization. Hence, avoidance of unnecessary transfers should be a primary goal, but when transfers are necessary, we support implementation of processes that optimize efficient and well-orchestrated patient transitions. We also encourage improved competencies of the entire interdisciplinary team in the SNF/NF setting, both as individuals and as a team, and more effective processes to ensure appropriate assessments are performed before the decision to transfer a patient to the hospital is made.

This white paper supplements AMDA’s previous white paper C-09, Improving Care Transitions from the Nursing Facility to a Community-Based Setting, which addressed transitions between the SNF/NF and the community.a AMDA supports care processes with a patient-centered focus emphasizing communication and appropriate documentation.

It is well established that there are significant deficits in the current system of care transitions, but there is limited evidence as to which interventions will most positively affect outcomes. We welcome additional data and new models of care that will help us create and evolve optimal processes for transitions between care settings. In the meantime, we propose some basic tenets that we believe, at least intuitively, will serve as underpinnings to enhance safe and efficient transitions:

  • Consistent discussion and documentation of advance directives and end-of-life care preferences, with up-to-date POLST (Physician Orders for Life Sustaining Treatment)/POST (Physician Orders for Scope of Treatment)/MOLST (Medical Orders for Life Sustaining Treatment)/MOST (Medical Orders for Scope of Treatment) forms or, in states where these are not available, with other appropriately executed advance directive forms.*
  • Education, communication, and engagement of patients and family as to the reason(s) for transfer, goals and next steps in care, the nature and severity of their conditions, appropriate health care provider contact information for problem solving, and optimization of the actual location of care to meet patient-specific needs.
  • Prompt and consistent medication reconciliation at every transition point, as well as proper planning to ensure no discrepancies in administration of medication.
  • Avoidance of harm to the patient and primary consideration of the patient’s individual preferences.
  • Retention of responsibility for the patient by the sending entity (ACH, SNF/NF, ED) until assumption of care by the receiving entity, and availability to respond to clinical inquiries from the receiving entity.

AMDA supports research, public policy, and best practices designed to improve the safety and efficiency of care transitions, and AMDA has recently published CPGs (e.g., Acute Change of Condition in the Long-Term Care Setting) to enhance care transitions specific to the long-term care setting. We hope that health care reform and future legislation will recognize and address the current deficits in care transitions and seek to reward seamless and reliable processes for transitions. This white paper focuses on specific issues of transfers between hospitals and SNF/NFs and vice versa, but we strongly support efforts to improve transitions across all care settings.