Q&A: Patient transfer questions for long-term care facilities and skilled nursing facilities

Q: When patients transfer to long-term care or skilled nursing facilities, they have basic information with them, but what questions should those facilities ask to make sure they have all the information they need to provide care?

A: Questions for the long-term care facility or skilled nursing facility caregivers receiving patients from the acute care hospital:

• Do you know the reason patients are sent to your facility?
• Do you know the patients code status?
• Do you have access to their advance directives?
• Do you have a contact name and phone number from the hospital?
• Do you have a family contact and phone number?
• Do you have a record of the influenza and pneumococcal vaccine for this patient?
• Do you have a list of the patient’s assistive devices (hearing aids, eyeglasses, dentures)?
• Do you know the patients’ medications, dosage, route, usual administration times, and last dose given?
• Do you know the patient’s current mental status?
• Do you know their current level of functioning (independent, dependent, falls risk)?
• Do you know the patient’s skin status (Braden score, pressure ulcers [stage, location, appearance])?
• Do you know the wound care and treatment?
• Do you know the patient’s diet, appetite, weight?
• Do you know the patient’s effective behavioral interventions – interventions used for fall prevention, agitation, or other behavioral issues?
• Do you know the contact case manager/social worker with phone number?
• Do you know type of intravenous line, size, length, and dressing, as appropriate?
• Do you know the results of significant diagnostic tests?
• Do you have access to the most recent consults?
• Do you have access to the most recent laboratory, EKG, and radiology results?
• Do you have the most recent therapy summary (weight-bearing status, transfer status, recommendations for continued treatment)?
• Are you aware of special equipment needs (mattress, bariatric equipment, Hoyer lift, wound vac, CPM)?
• Do you have pacemaker information (model number, etc., needed for recalls)?
• Are you aware of special treatment needs (radiation, dialysis, TPN, potential or actual hospice)?

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.