Organizers and Facilitators: Ruby Marr, David Haughey, Sachita Shrestha, David Bozaan, Dahlia Rizk, John Downs, Rafina Khateeb

Background

Transfer of patients from one hospital to another is a common practice, although the literature is largely focused on transfers for higher level of care to academic medical centers (AMCs) and/or tertiary/quaternary care hospitals. Increasingly, some AMCs have undertaken programs aimed at facilitating outbound transfer of patients from the AMC to regional affiliates. This motivated us to seek better understanding and define the current state of such transfers.

Through two well-established groups within Hospital Medicine: the Society of Hospital Medicine InterHospital Transfers Special Interest Group (SHM IHT SIG) and the Hospital Medicine ReEngineering Network (HOMERuN), eligibility was assessed using a Qualtrics survey and 13 AMCs were found to be eligible to participate. We then conducted semi structured interviews with 12 of them.

Five themes emerged.

Theme 1: Transfer Activity

Overview

• Most patient transfers are from AMC to an affiliated hospital within the same health system, specifically AMC Emergency Department (ED) to affiliate inpatient unit.
• Many (but not all) affiliate hospitals are directly owned by the AMC.

Transfer Purpose

• A goal described by most transfer programs is to increase ED and inpatient capacity at the AMC, often by ensuring full patient capacity at affiliates.
• Another identified goal is to improve access to specialized care available at affiliates (e.g., surgery centers of excellence).

Scale and Scope

• The number of affiliates within each health system ranged from 2 to 16. 
• While two programs transfer pediatric patients, most focus on transfer of adult patients.
• Number of patients transferred ranged from 1-200 a month.

Process and Metrics

• Many programs focus on affiliate exclusion criteria to avoid transfer of patients who require a service not available at the affiliate.
• All programs track metrics. While there is heterogeneity in this, the number of patients transferred is tracked by all, and most programs track the "boomerang rate" or number of patients transferring back to the AMC from the affiliate.

"The goal is the right bed for the right patient at the right time."

Theme 2: Facilitators

Institutional

• In systems where affiliate hospitals share a tax ID, patient transfer from the AMC ED to an affiliate is perceived as easier as the affiliate is financially/legally the same entity.
• Common EHR systems allowed seamless sharing of patient information and communication.
• Centralized transfer center to monitor available services and capabilities at affiliate sites and document all communication between the AMC and the affiliates during the transfer.
• When the affiliate site is closer to the AMC, patients are more likely to be transferred there compared to other sites.

Provider

• Shared providers between AMC and affiliates was identified as a crucial factor in improving the transfer process, fostered trust and continuity of care.
• Empowerment of a dedicated person or core group of hospitalists overseeing transfer was crucial for efficient patient transfer.

Patient

• Patients are more likely to accept a transfer if the affiliate site is closer to their home, as this proximity allows them to receive psychosocial support from family and friends.

"We usually got consent for the patient and family that came from two hours away, five hours away, eight hours away to come to the medical center, usually they want to go back once they hear that they no longer require care because getting family to be able to come and visit is usually a struggle."

Theme 3: Barriers

Conflicting Priorities/Interests

• Competing demands, including workload and patient condition.
• Capacity across institutions, while the inherent reason as to why these affiliations existed as described previously, affiliated institutions also had capacity challenges of their own at variable times.
• Interplay between level of care and desired patient populations.

Implementation and Operational Challenges/Gaps

• Triage complexity and the difficulties in understanding the inclusion and exclusion criteria for patients transferring to affiliates was challenging to readily know or understand.
• Lack of buy-in from patients/families and providers at both AMC and affiliate locations across progressions, and fear of change.
• Weak management systems to support patient selection and transfer contribute to manual and duplicate uncoordinated work causing inefficiencies, delays and frustrations.

Resources Impacting Operations

• Staffing shortages, especially during the pandemic.
• Transportation delays mainly due to staffing shortages.

Theme 4: Successes

• Improved care delivery.
• Increased patient/provider satisfaction.
• Growth in resources/services offered at affiliates.
• Improved relationships and understanding of priorities/needs between AMC and affiliates.
• Improved capacity management.

"We have found that things like readmission rates are much better in our affiliate heart failure program even compared to a similar population at the AMC."

Theme 5: Aspirations

• Growth of affiliations
• Expansion of populations/conditions
• Improvement of operations/management system.

Take-Home Points:

• Patient transfers are occurring from AMCs to affiliates as a means to manage capacity and/or improve access to specialized care within healthcare networks.
• Effective implementation of equitable and quality care delivery requires addressing operational inefficiencies and fostering institutional collaboration. 

Our next meeting will be on March 14, 2025.