Regulations: Transitions of Care Between Assisted Living Facilities and Hospitals

Moving assisted living residents to and from a hospital can be challenging. These challenges include:

• Notifying the resident’s legal guardian and physician of the transfer/hospitalization.
• Failing to provide appropriate treatment.
• Failing to address behaviors that may cause harm. This includes harm to residents or others.
• Providing information to ensure a safe, efficient transition. This includes:
  • A resident’s current health needs, including medications, dietary, nursing, physical, and mental health needs.
  • Names of medical providers.
  • Power of attorney/guardian information.
  • A contact person for additional information or updates.

Blue transfer envelope process

The blue transfer envelope process is a framework to help improve transitions of care. It also helps improve compliance with rules and resident outcomes.

A standardized transfer packet is used in the blue transfer envelope process. The packet contains information to help with transitions of care.

A blue envelope measuring 9 inches by 11 inches can be used to send transfer documents. These documents include:

• Client Transfer: Assisted Living Facility Client Face Sheet, F-02400.
• Client Transfer: Assisted Living Facility Capability, F- 02400A.
• Other documents to help with the transition process.

Complete the Client Transfer: Labels, F-02400B and place it on the outside of the envelope.

Resources

• Assisted Living Facility and Hospital Interface, P-02067 (PDF)—Offers guidance on the importance of having processes for transitions of care. This includes transitions to the emergency department. The document also provides tips for implementing the blue transfer envelope process.
• Assisted Living Facility and Hospital Interface Webcast—Explains the Assisted Living Facility and Hospital Interface, P-02067 (PDF) publication.