INSTRUCTOR'S GUIDE The transfer agreement, required by Medicare and Medicaid, is one important component of the programs which can take the nursing home out of the pattern of isolation into an effective relationship with the community's health and social resources. The community-wide transfer agreement could include not only the health resources - general hospitals, long-term care facilities, outpatient clinics, home care programs, public and voluntary health, welfare and rehabilitation agencies, and mental health services but also educational, recreational, and social agencies and services as well. "No single agency in any community can meet all of the complex needs of the long-term patient, yet without some central organization concerned with those needs, gaps and overlaps in long-term care are almost inevitable. The task of such a central agency is formidable because of the wide range in the needs of long-term patients, the multiplicity of ways through which care is financed, conflicting interests and pressures, the existence of outmoded facilities, and other factors. But the formidable nature of the task is matched by the urgency of need in every community."/1/ Under Medicare and Medicaid a nursing home must have a transfer agreement with at least one hospital (although this requirement may be waived under certain conditions). A transfer agreement is one which provides, in writing, for the transfer of patients between the hospital and nursing home whenever such action is medically appropriate, as determined by the attending physician. There must also be a provision for the interchange of medical and other information necessary or useful in the further care of persons transferred. Aside from the individual transfer agreement between a nursing home and a hospital, it is important to understand that, as an alternative, the activation of a community-wide transfer agreement is authorized by the Medicare conditions of participation. Although the Medicare requirement may be satisfied when a nursing home effects one transfer agreement with a single hospital, this solution would, under most circumstances, hardly meet the need since nursing homes usually receive and send patients to several hospitals in a community. In addition, some nursing homes have managed to make little headway in their efforts to effect transfer agreements with hospitals on a solo basis. The combination of a community-wide transfer agreement and use of a uniform inter-agency referral system would meet the usual communication needs of all hospitals, nursing homes, home health agencies and other health and social service programs in a community. The system would have wide application and be flexible enough to transmit information in any direction regardless of point of origin or diagnosis. Such agreements reflect the mutual planning and collaboration of hospitals, nursing homes and other agencies. /1/ Care of the Long-Term Patient, Chronic Illness in the U. S., Vol. II, 1956. Beyond the transfer agreement, there is the affiliation: "An affiliation is a formal agreement of mutual assistance, for the sharing of resources. Being a formal agreement, it involves extended consideration, or planning, to achieve a number of benefits: (1) It involves talking about the care of the patient and, specifically and ideally, it is a form of approval a way of extending the medical umbrella to provide needed care to patients, whatever type of facility they are in. (2) It is also a means of channeling financial resources to the (3) It is a means of getting economical use of services and personnel, by pooling such services as social work, physical therapy, and the like potentially the full range of services in the hospital. (4) It also provides excellent educational opportunities for personnel in both types of institutions. (We have a lot to learn from each other and these arrangements are a means toward such learning experiences.) "The major types of cooperation between nursing homes and hospital include: The objectives of a formal agreement between nursing homes and general hospitals are: 1. Development of specific patient transfer procedures. 2. Early involvement of the medical staffs of both institutions. 3. Prompt decision about shared services, if any. 4. Recruitment of personnel. 5. Use of one party's facilities by the other. 6. Method of financial operation. 7. Conduct of education programs. /2/ Kinzer, D.M., Executive Director, Illinois Hospital Association, Relations Among Health Care Facilities, Report of a Workshop, A.H.A., July 1964. "This last item is little thought of when agreements are in the making, but it is highly important, for it can result in better education of physicians, nurses and other personnel, particularly in the field of geriatric care. "The major essential elements suggested are the following: 1. 2. Identification of each institution and of the officers legally A statement of the general and specific purposes of the agreement. 3. Designation of a committee composed of representatives of each institution, who will facilitate the implementation of the agreement and conduct periodic review and revision. 4. A procedure for settling disputes arising under the agreement. 5. A statement that the agreement may be terminated by either party if certain qualifications are not maintained by either institution. 6. A procedure for alteration or termination of the agreement." /3/ "Good communication aids in coordinating activities. For instance, it is important to know promptly whether operations are proceeding in accordance with plans so that adjustments can be made when necessary. Moreover, there are a wide variety of activities, particularly those of detailed nature, that it is impractical to plan in advance, and coordination of these is achieved only as the people directing and performing them have current information regarding related work." /4/ In the health professions, effective communication is of great importance. Timing, choice of action, intensity of therapy, and even the patient's life may depend upon the accuracy and promptness of the interchange of information. In the field of continuing nursing care, communication is particularly important if the patient is to maintain or advance the recovery that took place in a hospital or rehabilitation center. The importance of uninterrupted service is especially pressing when rehabilitative procedures involve nursing responsibility. "To organize prompt exchange of precise information on the sick between the three principal groups concerned - the hospital and related institutions, the community health and welfare agencies, and the physicians and other professional persons in private practice. This is the three way information exchange.' /3/ Crosby, E. L., M.D., American Hospital Association States its Case for Affiliation, Nursing Home Administrator, Jan.-Feb. 1965. /4/ Newman, W. H., Administrative Action, 1951. 42-20 "The prerequisites for the initiation and operation of an effective referral system in a community are: 1. 2. Introduction of a standard referral form. An agreement between institutions and agencies to follow general 3. Initial and continued education of all professional personnel Each participating hospital, nursing home or community agency should designate a single service or person through which all recommendations for after-care are to be channeled, regardless of the person or service initiating the request. Use of a single unit or person as a clearing house for referrals will serve to coordinate and strengthen the work within the hospital or other facility or agency and improve the relationships among organizations. Utilization of the social service department (or the person responsible for this function in the nursing home or other agency) has the advantage of channeling referrals through a unit or person linking organizations and customarily operating in close contact with the health and social agencies in the community. /5/ Goldman, F., M.D., A Three-Way Information Exchange, Hospitals, October 1952. CASE STUDY ON UTILIZATION REVIEW CASE A THE DEVELOPMENT OF APPROPRIATE UTILIZATION REVIEW PLANS FOR NURSING HOMES UNDER VARIED CIRCUMSTANCES Background Information: Currently available nursing home beds for care of the aged in Tiller County total 250, of which 48 are in unlicensed facilities. These are distributed among six independent institutions ranging in capacity from 10 to 100 beds. Each operates under a significantly different set of circumstances, e.g., size, type of control, patient care program, caliber of administration and staffing, sources of income, and type of patients accepted for care. Two are unlicensed. The Fords, a 10-bed proprietary facility licensed as a "personal care" home, accepts ambulatory patients only; however, a person who becomes bedfast after admission is allowed to remain. Other than the administrator, who is an L.P.N., there are no professional employees. Less than half of the patients are under the supervision of a physician. The Fords is not geared for skilled nursing care or restorative services. Roadmere Nursing Home, a 28-bed proprietary facility, provides limited nursing skills and no rehabilitative therapy. A substantial percentage of the patients is without a personal physician. Roadmere is not licensed because of its inadequate physical facilities. It has no organized medical staff. Tiller County Nursing Home, a 60-bed county-owned and operated facility, is licensed for skilled nursing care. All patients are under supervision of physicians provided by the County. The medical staff is comprised of interns from the Medical Center and the County Physician (who is also the administrator of the nursing home). Skilled nursing care is lacking and the quality of rehabilitative therapy is questionable. Under the Home's Rules and Regulations, only medically indigent patients are admitted. These beds will not be available to Medicare beneficiaries who, by virtue of the law during periods of eligibility, would not be medically indigent. Scottish House, Inc., a 32-bed non-profit facility, which is licensed and exceptionally well staffed with skilled nursing personnel, is a Junior League project operated by a board of interested citizens. It does not have an organized medical staff. Wilderness Nursing Home, a 20-bed proprietary facility operated by a woman with no formal qualifications, is nevertheless a "pace-setter" in some ways. Each patient is required to have a personal physician. Skilled nursing hours per patient are unusually generous, with 24-hour coverage, and rehabilitative and personal services of various kinds are provided. As a result, the operator has been able to command a substantial premium over the prevailing rate structure in the area. However, there is no formal medical staff and the physical facilities do not fully meet requirements for licensure. |