Improving Transitions of Care between Assisted Living Facilities and Hospitals

Background

Over the past several years the assisted living industry has experienced challenges transitioning residents from their facilities to hospital settings including:

  • Notification of transfer/hospitalization to the client’s legal representative and physician.
  • Providing necessary information at the time of transfer to assure a safe, efficient transition (e.g. client’s current medications, dietary, nursing, physical and mental health needs, names of medical providers, power of attorney/guardian, name and contact information of a preferred contact person to contact for additional information or updates, etc.).
  • Failure to provide medication administration and clinical treatments appropriate to the client’s needs.
  • Failure to communicate and/or provide services to manage the client’s behaviors that may be harmful to themselves or others.

Implementation of Transitions of Care: Blue Transfer Envelope Process

The Assisted Living Facility and Hospital Interface Publication, P-02067 (PDF) was created in partnership with assisted living facilities, hospitals, advocates, and funding agencies. The purpose of this publication is to stress the importance of well-organized processes for transferring clients from assisted living facilities to and from hospital settings, including the emergency department, and provide guidance for implementing the blue transfer envelope process. The blue transfer envelope process is a standardized transfer packet containing necessary information to safely and effectively care for the client.

A blue 9” x 11” envelope can be used to package transfer documents including:

The completed Client Transfer Label, F- 02400B can be adhered to the outside of the envelope.

The blue transfer envelope process is not a "blueprint" for providers but rather offers a framework to improve the transition of care between settings, encourage regulatory compliance, and improve client outcomes.

Additional Resources

The following videos provide additional guidance on how to successfully implement the blue transfer envelope process:

Last Revised: December 6, 2019