Is quick reg process best for transfers?

Transfer patients pose unique issues

Patient transfer admissions pose a "bittersweet" issue for patient access managers, says Terry D. Long, RN, BSN, MBA, NEA-BC, director of the patient transfer center at Texas Health Resources in Arlington.

With more facilities utilizing computer documentation systems, the need for rapid admit of patients is paramount. "Clinical staff cannot provide any services to the patient prior to this patient access function," says Long. "The patient cannot receive diagnostic testing, supplies or procedures urgently needed. Clinical staff cannot document care performed or patient condition."

While transfer volume is needed to maintain volume and revenue, transfer patients have some specific issues not present in other patient populations. "Most patient transfers occur due to specific critical needs a patient experiences that cannot be met at their current hospital. This results in the need for a transfer," says Long. "These patients are usually critically ill and need services the moment they arrive at the accepting facility."

The patient arrives via helicopter and is rushed to surgery, the cardiac catheterization lab, or neonatal intensive care unit. How does the patient access staff admit this patient?

One common approach is to utilize a centralized bed control or transfer center to pre-admit the patient or utilize a reservation function in your admission/discharge/transfer (ADT) system.

"By having bed control or the transfer center enter the information into your ADT system prior to the patient leaving the sending facility, the admission can be processed utilizing your quick registration process," says Long. "This process is usually utilized in the emergency department. It works equally well in this case."

Other smaller facilities may have processes that include all transfers entering the facility via the emergency department, where access staff are accustomed to time-sensitive admission processes. "In hospital systems with one ADT system, most patients can be admitted to only one facility," says Long. "If a transfer moves to a second facility and is not discharged or transferred, then care may be affected at the second facility. "

Clinical input is key

At the Cleveland Clinic, a "throughput team" looks at the list of possible transfers to determine the order in which patients are sent, for all patients who don't qualify as a "come on down" for immediate placement. "We assess clinically what is going on with the patient. If you know the right clinical questions to ask, sometimes you get more accurate information," says Eileen Jamieson, RN, nurse manager of the throughput team.

"We look at that list constantly to judge and triage who needs to get here first. We want to get the sickest ones here sooner," says Jamieson.

When the Cleveland Clinic's nurse speaks to the nurse from the referring institution, the plan may change. "The nurse might say, 'This patient sounds really sick and needs to get here before the other one.' The clinical decision she makes would trump the decision that registration has made."

For the "come on down" patients who get a bed immediately, the financial clearance process is bypassed. But for other patients the referring facility calls about, the team makes sure that they have the correct patient and medical record number, and this is then faxed to the financial counselors.

"If the patient is out of network and has a condition that can be treated in network — if it's not something we offer that they can't get somewhere else — then the financial counselor tells them 'We'll be glad to take you, but you will incur a bill that you will be responsible for.'"

To ensure that transfer patients are placed in the appropriate status — observation or inpatient — nurses at Barnes-Jewish Hospital's patient placement center are trained to use an established set of criteria for the severity of illness and intensity of service that is required for hospitalization.

"Because we are a large academic medical center, we receive numerous referrals. Sometimes you have to balance the customer service aspect for the referring physicians over the payment issues," says Karen Gist, MSN, RN, ONC, director of patient placement and access at Barnes-Jewish Hospital in St. Louis, MO. "Sometimes we need to accept patients quickly and work on the care management issues on the back end."

For example, if a call comes in from a referring facility to transfer a patient to Barnes-Jewish, the physicians accept the patient based on the clinical picture. "And if they believe we are the place this patient needs to receive care, there is never a mention of the patient's insurance coverage," says Gist.

Once the transfer patient is admitted, case managers work with insurance carriers to try and ensure payment is received. "If they do not have insurance, they try to link them into a financial assistance program," says Gist. "But all of this takes place after the patient has been transferred to our organization. Patients are accepted based on their clinical need, not the ability to pay or have their insurance company pay."

[For more information, contact:

  • Karen Gist, MSN, RN, ONC, director, patient placement and access, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110. E-mail:
  • Eileen Jamieson, RN, nurse manager, throughput team, Cleveland Clinic, 5350 Frantz Road, Dublin, OH 43016-4259. Phone: (216) 445-7241. E-mail:
  • Terry D. Long, RN, BSN, MBA, NEA-BC, director patient transfer center, Texas Health Resources, 1701 East Lamar Suite 200, Arlington, TX 76011. Phone: (817) 404-1782. E-mail:]