C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 171
FIGURE 11-5
•
Transferring a client rapidly may be a life-saving measure.unstable condition but have recovered sufficiently to require less intensive nursing care.
Transfer Activities
Transferring a client to a different nursing unit is less complex than to another agency. In a transfer within the same agency, the nurse does the following:
• Informs the client and family about the transfer
• Completes a transfer summary(written review of the client’s current status) briefly describing the client’s current condition and reason for transfer (Fig. 11-6)
• Speaks with a nurse on the transfer unit to coordinate the transfer (the change of shift report in Chap. 9 can be used as a model)
• Transports the client and his or her belongings, med- ications, nursing supplies, and chart to the other unit When transferring the client to a nursing home or other facility, the nurse conducts the process similarly to a discharge: the client is discharged from the hospi- tal and admitted to the transfer facility. See Nursing Guidelines 11-1.
Extended Care Facilities
Older adults, in particular, may be transferred directly from an acute care hospital to a facility that provides extended care (Fig. 11-7). An extended care facility(health care agency that provides long-term care) is designed for
people who do not meet the criteria for hospitalization.
Although group homes for assisted living, adult day care centers, senior residential communities, home health care agencies, and hospice organizations (see Chap. 38) all fit this description, extended care generally is associ- ated with nursing homes. Nursing homes are classified
NURSING GUIDELINES 11-1
Transferring a Client
❙ Be sure to inform client and family of the need for a transfer as early as possible. Communication promotes cooperation.
❙ If time permits and the client and family have some choice, encourage them to investigate various facilities and collaborate on the one they prefer.The people most affected always should make the decisions.
❙ Communicate with the agency or unit where the client will be transferred.Other personnel need time to prepare for the client’s arrival.
❙ Make a photocopy of the medical record. A copy aids in continuity of care and avoids duplicating services.
❙ Provide a written clinical résumé, which is a summary of previous care (Fig. 11-6). It should include (1) reason for the hospitalization, (2) significant findings, (3) treatment rendered, (4) current condition, and (5) instructions, if any, to the client and family (JCAHO, 1998).
Check that the client has been notified and given consent for the release of his or her personal health information. To comply with privacy rules and data security standards set by the Health Insurance Portability and Accountability Act (HIPAA) in 1996 and further modified in 2001 and 2002 (see Chap. 9), the client must be informed and approve the release of health information among third parties for routine use in treatment.
❙ Place the written information in a large manila envelope or send them via facsimile (fax) machine with a cover sheet. Call the transfer agency to inform them to momentarily expect the fax. Under the revisions to the HIPAA privacy rules (2002), agencies must systematically protect the client’s personal health information within and outside the institution.
❙ Collect all the client’s belongings. Carelessness can lead to the loss of the client’s clothing or valuables and cause inconvenience in returning them.
❙ Accompany emergency medical staff or paramedics to the client’s room.Seeing a familiar face may reduce the client’s anxiety.
❙ Help transfer the client onto the stretcher. Assistance reduces physical demands on the client.
❙ Give the transfer personnel a copy of the medical record in a folder or envelope. Enclosing the record protects confidentiality and prevents loss.
❙ Complete the original medical record by adding a summary of the client’s discharge. Each medical record includes a discharge summary.
❙ Send the completed chart within a file folder to the medical records department.All charts are filed for future reference.
❙ Notify the business office, admitting office, and housekeeping department of the client’s transfer. Each department has its own responsibilities when a client leaves.
172 U N I T 4 ● Performing Basic Client Care
as skilled nursing facilities or those that provide interme- diate or basic care.
Skilled Nursing Facilities
A nursing home licensed as a skilled nursing facilitypro- vides 24-hour nursing care under the direction of a reg- istered nurse. The facility is reimbursed for the care of clients who require specific technical nursing skills. To qualify for skilled care, the client must be referred by a physician and require daily skilled nursing care. The fol- lowing are examples of common procedures that qualify:
• Care for a pressure sore
• Enteral feedings or intravenous fluids
• Bowel or bladder retraining
• Injectable medications
• Sterile dressing changes
• Tracheostomy care
Skilled care is provided from a multidisciplinary per- spective. In addition to a 24-hour team of nurses, a skilled nursing facility must provide rehabilitation services such as physical therapy and occupational therapy, pharma- ceutical services, dietary services, diversional and ther- apeutic activities, and routine and emergency dental services. Many of the latter services are provided by qual- ified people on a contractual basis rather than through full-time employment.
To qualify for Medicare benefits in a nursing home, a person must have been hospitalized for 3 or more days
FIGURE 11-6
•
A transfer summary provides information that promotes continuity of care.C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 173
within 30 days before needing skilled nursing care.
Clients who meet the criteria are eligible for 100 days of assistance with the costs. There is no charge for the first 20 days; for the next 80 days, Medicare pays all but
$119.00 a day (United States Department of Health and Human Services).
Some older adults have private insurance policies that assist with Medicare co-payments. If not, or if clients continue to require skilled care beyond 100 days, they must bear the cost personally until they are considered indigent. After clients have exhausted their own finan- cial resources and those of their spouse, they may apply to the state for Medicaid or its equivalent.
Intermediate Care Facilities
A nursing home also may be licensed as an intermediate care facility. This type of agency provides health-related care and services to people who, because of their mental or physical condition, require institutional care but not 24-hour nursing. Clients who require intermediate care may need supervision because they tend to wander or are confused. They need assistance with oral medications, bathing, dressing, toileting, and mobility.
Medicare does not provide reimbursement for inter- mediate care. Clients assume the costs. For impoverished residents, state welfare programs, such as Medicaid, will pay. Some nursing homes do not accept Medicaid clients, however, because states fix the fees for reimbursement at much lower amounts than Medicare and private insur- ance provide.
Basic Care Facilities
A third type of nursing home is a basic care facility(agency that provides extended custodial care). The emphasis is on providing shelter, food, and laundry services in a group setting. These clients assume much responsibility for their own activities of daily living such as hygiene and dressing, preparing for sleep, and joining others for meals. Intermediate and basic care may be provided at a skilled nursing facility but usually in separate wings.
Determining the Level of Care
The level of care is determined at admission. Each client is assessed using a standard form developed by the Health Care Financing Association called a Minimum Data Set for Nursing Home Resident Assessment and Care Screening.
By federal law, the Minimum Data Set (MDS) is repeated every 3 months or whenever a client’s condition changes.
The MDS requires assessment of the following:
• Cognitive patterns
• Communication and hearing patterns
• Vision patterns
• Physical functioning and structural problems
• Continence patterns in the last 14 days
• Psychosocial well-being
• Mood and behavior patterns
• Activity pursuit patterns
• Disease diagnoses
• Health conditions
• Oral and nutritional status
• Oral and dental status
• Skin condition
• Medication use
• Special treatments and procedures
Problems identified on the MDS are then reflected in the nursing care plan.
Selecting a Nursing Home
When the need arises, family members are often ill pre- pared for selecting a nursing home. A discharge planner can assist with arranging nursing home care. Brochures on selection are available from the American Association of Retired Persons, the Commission on Aging, and each state’s public health and welfare departments. Websites also provide valuable information. See Client and Family Teaching 11-1.
Areferralis the process of sending someone to another person or agency for special services. Referrals generally are made to private practitioners or community agencies.
Table 11-3 lists some common community services to