Reviewed updated steps for SNF to Acute care transfers from the August 24 call. Open questions about transfer/referral identifiers:

  • Transfer to ED is an identifiable event in the SNF system, so the system will assign the required referral ID.
  • When the patient is discharged from ED back to SNF, the identifier is used to close the loop.
  • If the patient is admitted to the hospital (post-ED), then the discharge is to follow the 360XL steps of request/accept/confirm/transfer
    • if the patient is not going to the originating SNF, then a new referral id will be created. At some point a notification to the originating SNF may have been sent with the originating referral id
    • if the patient is going back to the originating SNF, ideally, we want to use the originating referral ID.
      • Is this possible? It is not clear the ED/Hospital systems would have the original transfer information at this point. Something to check.

Reviewed the data elements for initial transfer to ED from Partners Healthcare.

  • Data is thorough, and extremely useful
  • Many SNF system have the data is some form
  • We will call for volunteers to find matches to C-CDA sections and entries.
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