​In New Jersey, transferring patients across the continuum of care has seen its share of problems regarding continuity and relaying accurate patient information. Developing and implementing a common transfer form to alleviate these issues was sorely needed to improve quality of care and reduce medical errors.

To address this need, health care facilities, home care providers, health care professionals, and other stakeholders worked with the state Department of Health and Senior Services (DHSS) to create and implement a mandatory Universal Transfer Form (UTF).

Getting Started

In late 2006, the UTF Task Force was launched with the New Jersey Hospital Association and the Health Care Association of New Jersey coordinating this statewide effort (see box, below).
The task force defined transfer as the handing off of responsibility for a patient from one facility or agency licensed by DHSS to another. The task force determined that it would be in the best interest of the patient if the receiving facility/agency had an up-to-date summary of essential information that was documented clearly on a standardized form to preserve continuity of care upon transfer.
This approach offered three advantages: All facilities would adjust their protocols for paper or electronic record systems to support the efficient capture of information needed to populate the mandatory form. Professionals receiving the new patient would know exactly where to look for the information needed to ensure continuity of care upon transfer. There would be a clear standard defining their duty to send accurate and complete information with patients upon transfer.
Exclusions included transfers between emergency departments; the return of an emergency department patient (who was not admitted to the hospital) back to his or her long term care facility; and special care needs patients, such as premature infants, newborns, and maternity care patients.
Voluntary compliance had failed in the past, so all stakeholders committed to using the UTF with the knowledge that the form would be mandated via state regulation.
All participants received numerous sample forms and transfer-of-care articles for review. The initial work concentrated on discussing and deciding what information was essential to include, as well as the degree of detail.

Keeping It Manageable

From the beginning, stakeholders were mindful of the concept that less is more. Too much information invited greater opportunities for errors of commission and omission. The task force decided to develop a form that captured essential information for continuity of care at the time of transfer and to encourage the sending provider to attach copies of relevant source documents appropriate to the needs of each patient.
Determining the best way to communicate medication information was especially challenging. Some stakeholders wanted a written list of current medications, while others wanted a copy of the physicians’ orders and medication administration records. Still others suggested that in accordance with The Joint Commission standards, a medication reconciliation document should be used.
Ultimately, the task force decided that the sending facility must include accurate information about current medications in a self-defined manner.
The initial draft was a two-page form. Page one contained essential information, and desired information was listed on page two. This allowed the sending facility to complete only the first page if the transfer out was an emergency, such as a nursing facility resident in need of immediate hospitalization.

Testing The Product

The draft form was pilot-tested in two phases. Phase one was a nonscientific, real-world mini pilot involving 10 facilities to determine if the draft form had major faults. The results of the pilot rendered minor suggestions to improve the form, which were adopted prior to the phase two trial.
Rutgers University was contracted to provide an objective, statewide phase two pilot test of the UTF.
The purposes of the phase two pilot were to gauge the acceptance of a UTF, identify ways to improve the form, highlight opportunities to effectively train staff in use of the UTF, and determine if the UTF was appropriate for a variety of facilities.
Five hospital systems and their referring and aftercare facilities participated in the phase two pilot.
The hospitals selected were in the northern, central, and southern areas of the state and were in both urban and suburban areas. The goal was to represent broadly the types of facilities that would be required to implement the UTF. Thirty-five facilities from these hospital systems participated in the pilot. This included assisted living facilities, home health care agencies, nursing homes, and rehabilitation hospitals. Some of these facilities offered multiple levels of care and specialized units, including mental health.
The 11-month field test yielded 546 UTF forms, 218 sender’s evaluation forms, and 10 receiver’s evaluation forms. Due to the low volume of receiver’s evaluations, Rutgers followed up by interviewing staff at receiving facilities.
In parallel during phase two, IGI Health created and pilot-tested an electronic version of the UTF with one hospital system and some of its post-acute partners. This was in anticipation of the expected development of and investment in more electronic health record applications in all care settings.

Form Still Too Long

Four themes emerged from the senders’ feedback: The form took too much time to fill out, the form was too long, staff members did not always have the information required, and there were various suggestions to omit or reduce specific areas. Receivers were pleased to have accurate and timely information on one form and offered ideas to reduce the length of the form.
Most importantly, the overwhelming majority of senders and receivers in the field were quick to recognize the inherent advantages of a standardized transfer form.
Based on their evaluation of the pilot, Rutgers made several recommendations that were adopted by the task force:
  • Shorten the form while including the necessary information to ensure a safe and effective transfer;
  • Include more staff members at future training sessions, incorporating a team approach rather than train-the-trainer;
  • Address the individual organizational process needs of each specific facility and network, including the types of electronic or traditional medical filing systems; and
  • Ensure that specialized facilities’ unique circumstances are addressed in the implementation of the UTF.
As a result, the form was reduced to a one-page document that captured the information needed at the time of transfer to ensure continuity of care. In addition, a comprehensive instruction sheet was developed to accompany the revised form.

The Final Transfer Document

In its final incarnation, information on page one included:
  • Name and telephone number for physician and sending facility contact person in the event that the receiving professionals have questions
  • Reason(s) for transfer
  • Code status
  • Pain along with other vital signs
  • At-risk alerts
  • Under-skin condition, identify if no wounds or the type of wounds
  • Identify attached documents
  • Require that the sending facility attach current medication information
In 2009, the final version of the UTF form and instructions were presented to DHSS. Following the administrative process for adopting regulations, in August 2011 the department finalized the rules for all 1,900 licensed health care providers and made the form and instructions available.
Electronic or paper completion of the UTF is permitted; considerable emphasis is being placed on electronic use of the form as a method to facilitate care transitions in concert with the goals of health care reform and the move toward health information exchanges.
Theresa Edelstein, MPH, LNHA, is vice president, post-acute care policy & special initiatives, for the New Jersey Hospital Association. She can be reached at tedelstein@njha.com. Daniel Moles, RN, BBA, MPS, LNHA, is president of TRANSITION HealthCare Consultants and Nursing Home Expert Opinion Services, Monroe Township, N.J. He can be reached at NHConsultant@comcast.net