Continuity of Care Transfer Project

The Continuity of Care Transfer Project is a recommended process to communicate timely, accurate and complete information when patients and residents are transferred to and from hospital emergency departments, nursing units and LTC communities. The project’s aim is to improve the quality, safety and continuity of care transitions between these care settings.

The Best Practice Guide to Action presents an overview of a transfer process developed by the Missouri Department of Health and Senior Services’ LTC Best Practice Coalition in collaboration with hospitals and LTC centers. The collaboration resulted in the determination of necessary information to be communicated and the development of processes and tools to improve handoff communication when transfers occur.

Resources
Note: Users may need to download Adobe Acrobat Reader to access these files. This program is free.

• Hospital Invitation to LTC Centers
• Hospital Post-Discharge Chart Review Tool
• Hospital to LTC Model Transfer Form Guideline
• Hospital to LTC Model Transfer Form
• Hospital Performance Measure Tool
• Hospital Employee Survey
• Hospital Staff Education PowerPoint Presentation
• Hospital Administration PowerPoint Presentation
• LTC Model Transfer Form Guideline
• LTC Model Transfer Form
• LTC Performance Measure Tool
• LTC Employee Survey
• LTC Administration PowerPoint Presentation
• LTC Staff Education PowerPoint Presentation
• Emergency Department Model Transfer Form Guideline
• Emergency Department Model Transfer Form

 Other Resources

• Early Warning Report
• Patient PASS: A Transition Record
• Project Boost
• Safer Handoffs of Older Adult Patients
• Unplanned Transfer Assessment