At every level of treatment, the resident’s length of stay is getting shorter and shorter. Post Acute Care facilities are starting to see sicker patients for shorter stays, and we are discharging sicker patients back home with home care to follow. When thorough communication between caregivers at each level of care does not take place, we risk creating an environment that will allow patient harm to occur.

All patients deserve to have accurate and thorough medical information passed along to all caregivers who have a need to know. This is especially important when transitioning a patient from one level of care to another, as illustrated in the patient scenario below.

A patient was admitted to an IRF for post spinal surgery management. The facility did not receive a thorough report. The patient had a very complex medical history, but the report sent to the IRF focused only on the spinal surgery and necessary rehab. During the post acute stay at the IRF, the patient became confused, got out of bed independently, fell, fractured a hip — and subsequently had to return to the hospital for surgery.

This additional complication was a huge setback for the patient. When the investigation was completed, it was discovered that at the time of transfer from hospital to the IRF, the medication list was not complete. A complete medical history did not accompany the patient either — only the most recent information regarding the spinal surgery. Without thorough information, the facility was not able to recognize early symptoms and intervene to prevent the onset of the patient’s significant confusion and cascade of errors that occurred following.

This is just one example of an error occurring due to poor handoff.

Almost always, the #1 root cause of any adverse event is poor communication between care providers.

Unfortunately, until the time that a universal UHR is available, we will have to rely on “the handoff”. Fortunately, Functional Pathways has a way to tackle this problem in the present: the Transfer of Care Form.


Utilizing a Transfer of Care Form

By partnering with your referral bases (referring hospitals, home care agencies, skilled facilities, and outpatient clinics) to create a Transfer of Care Form that will be used by all, you can greatly reduce handoff communication errors and deliver better patient care. It is  tried, true, and essential. This patient report needs to capture ALL key information the receiving caregiver will need to provide quality treatment. Strong communication is all about the handoff.