Statewide collaboration to improve transitions of care: developing a universal transfer form

Presented at Society of Hospital Medicine, 03/25/2104, Las Vegas, NV.Background: New Mexico is geographically large, rural and medically underserved. Thirty of New Mexico’s 33 counties are designated as Medically Underserved Areas and Health Professions Shortage Areas. Many New Mexico patients are transferred from urban hospitals to skilled nursing facilities (SNFs), often in other parts of the state. When compared to all states using the 2012 Leapfrog Composite Safety Score for U.S. Hospitals ratings, New Mexico ranked last (50 of 50 states) in overall hospital patient safety. Purpose: The Hospitalist Committee of the New Mexico Chapter of the American College of Physicians recruited a volunteer working group of 20 hospitalists, medical directors, patient safety officers, nurses and resident physicians from across the state to develop at least one intervention designed to improve patient safety in New Mexico hospitals. Description: The group participated in monthly conference calls. After discussing ideas about interventions to improve hospital patient safety and how to implement them, the group agreed to focus on developing a state-wide form to facilitate transfer of important clinical information to providers who receive patients at SNFs from New Mexico hospitals. Subgroups reviewed forms used across the state and developed and conducted a survey of Medical Directors of New Mexico SNFs. The group used a free internet wiki-site to post documents and share information. The group reviewed five New Mexico hospital transfer forms that were currently in use. Eighteen separate elements were identified on these forms, none of which were common to all 18 forms. New Mexico SNF Medical Directors completed an anonymous voluntary internet-based survey. Frequent concerns expressed by the surveyed directors included receipt of too much superfluous information; frequent lack of important clinical care items (code status, decisional capacity, weight-bearing status, end date of antibiotics, anticipated duration of anticoagulant therapy, recommendations for follow-up appointments, and name of the patient’s primary care provider); and lack of a direct contact telephone number of the referring provider. Using the survey results and a review of the existing forms, the group drafted and approved a one-page state-wide transfer form which has now been made available to the 32 hospitals in New Mexico. The project was completed in eight months with 6 conference calls at a total cost of less than $400. Conclusions: Using cross-state collaborations, voluntary professional time, conference calls and a wiki-site, this low-cost project produced a state-wide transfer form designed to enhance safer transitions of care in a large rural state