CASE STUDY

TRANSFER AGREEMENT

THE DEVELOPMENT OF A TRANSFER AGREEMENT BETWEEN A

NURSING HOME AND A HOSPITAL

Possible Solutions to Problems and Discussion:

What steps should you as administrator take to work out transfer agreements with the hospitals?

а.

b.

C.

You should review the alternatives with the Board of Directors
(individual agreements with the various hospitals or a community-
wide agreement).

1)

2)

"Community-wide" means a joint or "master" agreement between
facilities that qualify as extended care providers under Medicare
or as skilled nursing homes or intermediate care facilities under
Medicaid with one or more hospitals in the community. (Note:
"When the transfer agreement is on a community-wide basis, it
reflects the mutual planning and agreement of hospitals, extended
care facilities and other related agencies." Conditions of
Participation; Extended Care Facilities, Section 405.1133_/.)

"Individual" means a one-to-one relationship between an extended care facility and/or a nursing home and a hospital.

If the decision is made to try to implement a community-wide agreement, probably the best approach would be to contact the county nursing home association to see what the thinking is in this group.

1)

2)

If the nursing home association concurs in the value of a joint plan, they might approach the county medical society, the local hospital council, or a local health planning council to request assistance.

An approach also might be made to the state hospital association
and/or the State Medicare agency or the State Medicaid agency
for advice and assistance in getting cooperation with the
hospitals. (Note that only three general hospitals are involved.
The Barton Army Hospital admits only military personnel and
their dependents.)

If the decision is to set up individual agreements with the hospitals, you as administrator must plan your approach to the hospitals.

1)

Since an informal agreement already exists with Fernville Hospital, you will have to discuss with Dr. Prince the content of a formal agreement and perhaps recommend a transfer agreement form to him which spells out the areas of joint responsibility.

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2)

In order to approach the medical center's administrator and the
head at the Catholic hospital, you might find it advantageous to
be introduced through a physician on the staff, if you know one.
Otherwise, you will need to contact these administrators
directly to seek cooperation and to discuss the service
Colonial Hills can provide to the long-term patient. Here
again, the principles involved in a transfer agreement should
be, discussed and a possible form for the agreement reviewed.

What principles are involved in developing a transfer agreement?
The rationale underlying a transfer agreement involves:

a.

b.

1)

seeking to improve the continuity of patient care,

2)

increasing utilization of hospital and nursing home beds,

3)

4)

improving the mechanics of patient transfer (beyond the
existing system),

improving the community's understanding of the role of the
nursing home in relation to the hospital.

Essentials of a workable transfer agreement:

provision for prompt transfer to the nursing home,

adoption of a standard patient transfer form and procedures for
its use,

agreement for priority for readmission of the home's patients
to the hospital,

1)

2)

3)

4)

improved communications between hospital and nursing home,

5)

education of physicians to the importance of the program,

6)

improvement of the "image" of nursing homes by means of good
public relations techniques.

What are the relative merits of community-wide and individual transfer agreements?

a.

A community-wide agreement can encourage joint involvement which can carry over into many other areas of community cooperation and functions required of nursing homes and hospitals under Medicare and Medicaid; i.e., utilization review, patient care policies, medical review, relations with other professional personnel, cooperation with hospitals in in-service training in nursing homes, etc. A community-wide agreement reflects the mutual planning and agreement of hospitals, extended care facilities, and other related agencies.

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4.

5.

6.

b.

Individual transfer agreements may result in differing policies
and procedures to follow, which could cause confusion. One
hospital may demand preferred treatment at the expense of another.
However, since Medicare requires only an individual transfer
agreement, this may be a necessary starting point. Note that an
informal transfer agreement with Fernville Hopsital already exists.

Where can advice be obtained as to the form of transfer agreement to be used?

a.

b.

C.

d.

nursing homes and/or hospital associations,

U. S. Public Health Service (Department of Health, Education, and
Welfare); State or local health departments,

legal advisor,

medical society (more assistance from this group would probably be
forthcoming on implementing the transfer agreement).

Can your facility be a signatory in a community-wide transfer agreement
and still give preferred status to one or more hospitals?

a. If a hospital is not a signatory on a community-wide transfer agree-
ment and wants to sign an individual agreement with one or more of
the nursing homes, there is nothing in the Conditions of Participation
to prevent it.

What if you cannot reach agreement with one or more of the hospitals in
the community?

a.

If the extended care facility has copies of letters, records of
conferences, and other evidence to support its claim that it has
attempted in good faith to enter into a transfer agreement, the
facility can be presumed to have such an agreement in effect, if
it is also found that to do so is in the public interest and
essential to assuring extended care services for patients in the
community eligible for benefits. (Conditions of Participation;
Extended Care Facilities, Section 405.1133, "Transfer Agreement").

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References:

A.H.A. States its Case for Affiliation, Edwin L. Crosby, M.D., Nursing Home
Administrator, vol. 19, no. 1, January-February 1965.

Nursing Home Administrator, vol. 19, no. 3, May-June 1965.

Nursing Home - Hospital Affiliation:

It Works and Here's How, Lawrence C. Davis,

Nursing Home Administrator. vol. 19, no. 3, May-June 1965.

Model Transfer Agreement (attached), Nursing Homes, September 1966.

Sample Formats for Transfer Agreements: Hospitals and Nursing Homes. Massachusetts Hospital Service, Inc., 1966. (See sample individual and community-wide transfer agreements, attached).

U. S. Department of Health, Education, and Welfare: Social Security Administration, Conditions of Participation; Extended Care Facilities. HIR-11, February 1968.

The Affiliation of an Institution for the Care of the Long-Term Sick (Beth
Abraham Home) with a Neighboring General Hospital (Montefiore Hospital),
Bernard N. Brodoff, M.D., Martin Cherkasky, M.D., and William Adelman,
Journal of Chronic Diseases, vol. 16, 1963.

Recommendations of Workshop on Hospital-Nursing Home Relationships. American
Medical Association, 1960.

A Guide for Hospital Nursing Home Affiliation. Illinois Hospital Association, 1961.

Guiding Principles for Agreements Between General Hospitals and Long-Term Care Facilities. American Hospital Association, 1963.

Q and A on Agreements Between General Hospitals and Long-Term Care Facilities,
John F. Horty. American Hospital Association, 1964.

Minneapolis Forges a New Communication Tool:, W. E. Park and D. Hughes,
Hospitals, May 19, 1965 (Form H-465-1964, attached).

Patient Care in Nursing Homes:

A Look at Responsibility, Journal of the

American Medical Association, vol. 200, no. 2, April 10, 1967.

Standards for Accreditation, Extended Care Facilities, Nursing Care Facilities, and Resident Care Facilities. Joint Commission on Accreditation of Hospitals, January 1968.

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Public Law 89-97, The Social Security Amendments of 1965.

Public Law 90-248, The Social Security Amendments of 1967.

Transfer Agreements Between Extended Care Facilities and Hospitals, American Hospital Association, 1966.

U. S. Department of Health, Education, and Welfare: Public Health Service, Medical Profile: Dixon, Tiller County/U.S.A., Teaching Reference Community, 1967.

Case prepared by:

Benjamin Latt, M.S.

Management Consultant

Nursing Homes and Related Facilities Program
Division of Medical Care Administration

Public Health Service