Transferring a loved one from one skilled nursing facility to another is a common process that often feels complicated for families. Transfers are typically driven by a desire for better care, specialized services, or proximity to family members. Navigating this transition requires careful planning, an understanding of patient rights, and coordination of medical and logistical details. This article provides a straightforward, step-by-step guide to manage the transfer process smoothly.
Initial Planning and Selecting the New Facility
The process begins by identifying why a move is necessary, such as proximity to family, unmet patient needs, or a desire for a different atmosphere. Once the decision is made, thorough research is required to vet potential new homes. Families should utilize official comparison resources, such as state or federal nursing home rating websites, to evaluate facilities based on quality measures, staffing levels, and inspection results.
After identifying a suitable facility, confirming financial clearance is necessary before finalizing any transfer. If the patient relies on government programs, the family must confirm that Medicare or Medicaid covers the stay at the new location. For private insurance or self-pay arrangements, a review of the new facility’s contract and billing structure is required. Securing this commitment prevents unexpected financial burdens or service interruptions.
Patient Rights and Essential Documentation
Federal regulations protect a resident’s right to choose their provider, meaning the current facility cannot obstruct a voluntary transfer initiated by the patient or representative. This right is grounded in regulations such as 42 CFR § 483.15, which outlines resident admission, transfer, and discharge rights. The patient or their legal representative must formally notify the current nursing home in writing of the intent to transfer and the chosen destination.
Collecting patient documentation is an important administrative step to ensure continuity of care at the new facility. The current nursing home is legally obligated to provide a complete set of medical records upon transfer. This documentation must include the current medication administration record (MAR), the most recent comprehensive care plan, and any physician’s orders or recent physical examination results.
Copies of advance directives, such as a Do Not Resuscitate (DNR) order or Power of Attorney for Healthcare, must also be included. These documents ensure the new care team understands the patient’s preferences and legal representation. Facilities are required to provide this information in a timely manner so the receiving nursing home can prepare for the patient’s arrival.
Coordinating the Physical Transfer
Once the new facility accepts the patient and all paperwork is in order, the family must coordinate a specific date and time for the move. Scheduling requires clear communication with the discharge coordinator at the current facility and the admissions team at the receiving facility to minimize waiting times. Coordination of medical transportation is often the family’s responsibility, depending on the payer source and the patient’s medical needs.
For patients who are non-ambulatory or require continuous monitoring, specialized non-emergency medical transport (NEMT) or an ambulance is necessary. The mode of transport depends on the patient’s condition, utilizing vehicles equipped for stretchers or wheelchairs. Families should confirm that the transport provider’s drivers are trained to handle patients with mobility or behavioral needs to ensure a safe, bed-to-bed transfer.
The discharging facility must finalize a comprehensive discharge summary on the day of the move, providing the most up-to-date account of the patient’s status. This summary must include a final medication list with any recent changes or discontinuations clearly noted. This documentation is handed over to the transport team or family to be delivered to the receiving facility upon arrival.
Ensuring Care Continuity After Arrival
Upon the patient’s arrival, staff must immediately initiate medication reconciliation to prevent errors. This involves a clinical review where a nurse or pharmacist compares the physician’s orders against the actual medications and the discharge summary. Any discrepancies between the incoming medication list and the standing orders must be assessed and resolved before the first dose is administered.
A staff member will conduct an immediate intake assessment to determine the patient’s current functional and medical status, noting any changes since the initial acceptance. This assessment forms the foundation of the patient’s new individualized care plan. The initial days are a period of adjustment, and staff will monitor the patient for signs of distress or disorientation.
Families should maintain close contact with the new care team during the first week to address concerns regarding documentation or care routines. Follow-up communication with the unit nurse or social worker is recommended to ensure the incoming records are fully integrated into the facility’s electronic health system. This partnership promotes a smooth transition and rapid establishment of care.