Development and Implementation of a Universal Transfer Form The New Jersey Journey Toward Improved Transitions

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1 Development and Implementation of a Universal Transfer Form The New Jersey Journey Toward Improved Transitions Healthcare Quality Strategies, Inc. 557 Cranbury Road Suite 21 East Brunswick, NJ Phone: Fax: This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NJ-C /2013

2 Housekeeping Materials are available for download in the Share tab Discussion and Q&A will follow the presentations You can use the Chat feature to submit a comment or question during the presentation Please submit your comment or question to All Participants We will review them in the order that they are received 2

3 Today s Presenters New Jersey Hospital Association Theresa Edelstein, MPH, LNHA Vice President of Post-Acute Care Policy & Special Initiatives TRANSITION HealthCare Consultants Daniel Moles, RN, BBA, MPS, LNHA President Healthcare Quality Strategies, Inc. Andrew Miller, MD, MPH Medical Director Greenwood House Deborah Hunter, RN Assistant Executive Director New Jersey Department of Health Division of Health Facilities Evaluation and Licensing Alison Gibson, RN, MA, MPA Assistant Commissioner Kareen Villano, RN, BSN Supervising Health Care Evaluator Eugene Brenycz, JD, MPA Regulatory Officer 3

4 Opening Presenters Theresa Edelstein, MPH, LNHA Vice President, Post-Acute Care Policy & Special Initiatives New Jersey Hospital Association Daniel Moles, RN, BBA, MPS, LNHA President TRANSITION HealthCare Consultants

5 This session will cover New Jersey Universal Transfer Form (UTF) What is it? Why was it done? How was it developed? How did it evolve? When and how was it implemented? How is it working? 5

6 What is the New Jersey UTF? A statewide, mandatory use transfer form Patient/resident transfers between state licensed health care facilities and programs To/From From/To Hospital (acute, rehabilitation, mental health) Hospital (acute, rehabilitation, mental health) Hospital SNF, ALF, Sub-acute Care, Hospice, Home Care, Other SNF, ALF, Sub-acute Care, Hospice, Home Care, Other SNF, ALF, Sub-acute Care, Hospice, Home Care, Other Exclusions Emergency Department Emergency Department Emergency Department Return to Other Settings 6

7 Origin of the UTF Past Unsuccessful Attempts Associations American Medical Directors Association (AMDA) Regional providers efforts New Jersey Regulation Widespread Recognition of Need New Jersey Department of Health (NJDOH): Complaints, Errors Health Care Association of New Jersey (HCANJ): Medication Management Best Practice Guideline New Jersey Hospital Association (NJHA): Pressure Ulcer Collaborative (PUC) American Medical Directors Association (AMDA): Transfer Form Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): Medication Reconciliation 7

8 Volunteers: UTF Task Force Participants A Bottom Up, Provider/Profession-Driven Initiative NJDHSS NJHA Hospitals/long-term care facilities LeadingAgeNJ Nonprofit long-term care facilities HCANJ/NJALC long-term care and assisted living facilities AMDA New Jersey chapter ER/ED Nurses New Jersey- Emergency Nurses Association (ENA) Medical Society of New Jersey New Jersey Association for Directors of Nursing Administration (NJADONA) EMS professionals Home Care Association New Jersey Center for Lifelong Learning New Jersey Hospice & Palliative Care Organization (NJHPCO) Healthcare Quality Strategies, Inc. (HQSI) Quality Improvement Organization for New Jersey Various facility/provider representatives Physicians Nurses Infection control professionals Behavioral health settings 8

9 Advantages of UTF Establish clear standard Communication between providers Efficiency of process sending and receiving Quality of care at transition Patient/resident/family satisfaction Reduce readmissions Goal: Paper UTF; Electronic Health Record (EHR)-friendly 9

10 UTF Development: Challenges What Information to Include Paradox: Less is More; More accurate and useful How Many Pages? Will Providers Embrace the Idea? Accurate, Timely Medication Information Essential, But What Way is Best to Capture and Communicate This? Will Health Department Mandate a Form? Can One Form Serve All Settings? Little Known About EHR Language and Systems What Information to Omit 10

11 UTF Pilot Test: Two-Page Form Page 1: Essential Information Page 2: Desirable Information Test: Phase One Initial, brief trial at 10 facilities Minor changes to form 11

12 UTF Pilot: Phase Two Funded by Civil Monetary Penalties (CMP) dollars Planned six months, took 11 months Rutgers University Research Team Formal evaluation tools Diverse, representative sample; five hospital systems 35 facilities/programs Onsite education and follow-up Well-organized feedback; 546 UTFs, sender and receiver evaluations 12

13 Back to Basics: Redo UTF Based upon comprehensive pilot, form was: Too long Took too much time to complete Information often not available Pilot participants enthusiastic about the idea of a UTF, offered good suggestions One page UTF emerged 13

14 UTF Highlights Easy to complete: check boxes EHR: Computer may pre-populate data fields [5] Name/number for physician [6] If known, check off Code Status [8] Clearly state reason(s) for transfer [8] Include pain information as fifth vital sign [10] If needs restraints, say why in section 8 (per instructions) 14

15 UTF Highlights continued [15] Skin: document if no wounds; wound type [18] Document personal items sent with patient [19] Attach relevant existing documents [19] MUST attach current medications and last dose [20] Identify at-risk alerts (none, falls, wanders) [21] If mental status change is reason for transfer, explain in section 8 (per instructions) [27] Sender s contact, name/number if questions 15

16 Links to UTF Documents and Publications UTF as.pdf: UTF as.doc: UTF Instructions: 7_instructions.pdf UTF FAQs: m_faq.pdf Provider; UTF Article: /Pages/0112/State-Makes-Universal-Transfer-Form- Mandatory.aspx 16

17 To improve the UTF, please offer comments/feedback to: Loretta Kaes, BSN, RN, LNHA, CALA Director, Quality and Clinical Services Health Care Association of NJ Theresa Edelstein, MPH, LNHA Vice President, Post-Acute Care Policy & Special Initiatives New Jersey Hospital Association

18 The New Jersey Universal Transfer Form March

19 Universal Transfer Form Division of Health Facilities Evaluation & Licensing Alison Gibson, Assistant Commissioner, Health Facilities Evaluation and Licensing - (609) Kareen Villano, Supervising Health Care Evaluator Office of Assessment and Survey Eugene Brenycz, Regulatory Officer, Office of Certificate of Need and Licensing Department NJ Department of Health and of Senior Health Services 19

20 Universal Transfer Form Benefits of the UTF A Commitment to Safety A Commitment to Improving Quality A Commitment to Patients and Residents Department of Health Process Enforcement Department NJ Department of Health and of Senior Health Services 20

21 Universal Transfer Form FAQs Department NJ Department of Health and of Senior Health Services 21

22 FAQs Q. Which healthcare providers are required to use the UTF? A. All health care facilities and programs licensed by the Department of Health (DOH) are required to use the UTF. Q. Does a registered nurse have to fill out the UTF? A. No. In some instances, a nurse is not always in the facility or the home when the patient is being transferred. If more information is needed the receiving facility can follow up with the sending facility. Department NJ Department of Health and of Senior Health Services 22

23 FAQs Q. Will this requirement be extended to other licensed healthcare entities, specifically healthcare service firms and nurse registries which are under the Department of Law and Public Safety, Division of Consumer Affairs (DCA)? A. DOH cannot extend the UTF to healthcare service firms or nurse registries because they do not fall under our authority, as they are not licensed healthcare facilities or programs. It would take action by DCA to have the UTF extended to nurse registries and healthcare service firms. Department NJ Department of Health and of Senior Health Services 23

24 FAQs Q: Where do we obtain copies of the UTF? A: Interactive copies of the UTF are available on DOH s website for download. If you choose to go to a carbon copy or any other type of UTF, the facility has to have copies made on its own. Q. How can I find out if a healthcare provider is licensed by DOH? A. A search for licensed healthcare facilities and providers can be performed on the Department s website at the following web address, Department NJ Department of Health and of Senior Health Services 24

25 FAQs Q: If a patient is discharged and case management made a follow-up physician appointment, do we need to send a UTF? A: If the physician s appointment is at a licensed healthcare facility, such as an ambulatory care facility, the UTF is required. If the appointment is at the physician s private practice office, the UTF is not required. Q. My facility received a patient who came in with a UTF can I just copy it and write no change? A. No, you would need to complete a new UTF with the information that you have. Department NJ Department of Health and of Senior Health Services 25

26 FAQs Q: Why is it that there is no place for insurance information on the UTF? A: Because insurance information is not relevant to patient care. Often a copy of the face sheet will be attached to the UTF and that usually has insurance information on it. So, you can add the face sheet or include the insurance information on another attachment. Q. Has a template been developed for policies and procedures, as required by N.J.A.C. 8:43E-13.5, regarding the use of the UTF? A. No, there is no template as the Department does not develop policies and procedures. Department NJ Department of Health and of Senior Health Services 26

27 FAQs Q: The expectation is to complete the UTF to the best of our ability. At a minimum what needs to be filled in? A: The information that the facility must include on the UTF is the information requested on the UTF that the facility has available. Q. Can the numbering of the sections on the UTF be changed? A. No, the sections must be numbered the same as on the UTF, designated the HFEL-7 by DOH Department NJ Department of Health and of Senior Health Services 27

28 FAQs Q. Can a facility pre-populate the UTF? A. Yes, the UTF can be pre-populated. There is a signature box for the individual who prepopulates the UTF. Q. Instead of filling out the whole UTF can I write see attached? A. No. The UTF must be completed. Attachments may be attached to the UTF if required by Section 19 or if the attachment has useful information for the patient s care. Department NJ Department of Health and of Senior Health Services 28

29 FAQs Q. Section 19 lists a number of possible attachments, what do I need to attach? A. If you have an item contained in Section 19, you have to send it as an attachment. Q. How far back do I need to go in regard to the attachments in Section 19? A. You should go as far back with the attachments that are relevant to the patient s current condition. For example, if labs are run regularly, you don t need to send them all, but at a minimum the last set of lab results are to be attached. Department NJ Department of Health and of Senior Health Services 29

30 FAQs Q. What do I do if EMS is here and the UTF isn t finished? A. Don t wait, send what you have ready with EMS and then follow-up ASAP with the rest of the information. Q. What is the most appropriate medication information to include with the UTF? A. A copy of the medication administration record, with the last dose of each medication recorded, is to be attached. Current medication information must be sent. Medication reconciliation, if available, should be attached to the UTF as well. Department NJ Department of Health and of Senior Health Services 30

31 FAQs Q. Does an electronic version of the UTF need to be identical to the HFEL-7? A. No, but the electronic version needs to be substantially similar to the HFEL-7. This means that an item in the upper left hand corner of the HFEL-7 should be in the upper left hand corner of the electronic version, even if it isn t in the exact same spot or in the same font. In addition, the number assigned to each information box on the paper UTF must be assigned to the electronic version of the UTF, as these numbers correspond to the numbers on the UTF instructions. Department NJ Department of Health and of Senior Health Services 31

32 FAQs Q. Does an electronic version of the UTF still need to be one page? A. Yes. Q. Can a facility or program add items to an electronic version of the UTF? A. Items are not to be added to the UTF itself, as the UTF is meant to be a Universal form, but a facility or program can include items deemed relevant as attachments. Department NJ Department of Health and of Senior Health Services 32

33 Universal Transfer Form Thank You! Department NJ Department of Health and of Senior Health Services 33

34 This Power Point presentation is an educational tool prepared by the Department of Health that is general in nature. It is not intended to be an exhaustive review of the Department's administrative code and is not intended as legal advice. Materials presented should not be a substitute for actual statutory or regulatory language. Always refer to the current edition of a referenced statute, code and/or rule or regulation for language. Department NJ Department of Health and of Senior Health Services 34

35 Transitions of Care and the Universal Transfer Form Healthcare Quality Strategies, Inc. 557 Cranbury Road Suite 21 East Brunswick, NJ Phone: Fax: Andrew Miller, MD, MPH Medical Director Healthcare Quality Strategies, Inc. 35

36 Reducing readmissions is not only a hospital problem; it is a community problem Need effective communication and coordination among all providers in the community 36

37 Examples of Transitions of Care Nursing home to home care agency Hospital to dialysis facility Assisted living facility to hospital 37

38 Reducing Readmissions Need multiple strategies no one intervention by itself will do the job However, all interventions benefit from effective, timely and/or complete communication between providers 38

39 What is Needed for Good Transitions Effective processes for discharges/transfers handovers Reliable systems for sharing key clinical information UTF Effective patient/caregiver education Patient/caregiver involvement in care Appropriate services in the community 39

40 End-of-Life Care End-of-life care options, such as POLST, are not focused on improving transitions of care However, end-of-life care options are important ways to prevent unwanted readmissions The New Jersey UTF captures patient s wishes for end-of-life care 40

41 The New Jersey UTF Is not the solution Is one part of the solution Standard process Timely transfer of information Reliable If it is used consistently Completed accurately 41

42 Provider Success Story Deborah Hunter, RN Assistant Executive Director Greenwood House 42

43 Greenwood House Skilled nursing, rehabilitation, and assisted living in Ewing, New Jersey Offering homemaker services and hospice care Facility houses137 beds Staff provides care and support 24 hours a day, 7 days a week Over 225 full and part-time health care professionals Over 100 licensed and certified nursing professionals 43

44 The UTF in Action at Greenwood House The UTF informs providers and improves patient care What our staff likes about the UTF: Sending Receiving 44

45 Presenter Contact Information Eugene Brenycz, JD, MPA Regulatory Officer Department of Health, Division of Health Facilities Evaluation and Licensing Alison Gibson, RN, MA, MPA Assistant Commissioner Department of Health, Division of Health Facilities Evaluation and Licensing Kareen Villano, RN, BSN Supervising Health Care Evaluator Department of Health, Division of Health Facilities Evaluation and Licensing Theresa Edelstein, MPH, LNHA Vice President of Post-Acute Care Policy & Special Initiatives New Jersey Hospital Association Deborah Hunter, RN Assistant Executive Director Greenwood House Andrew Miller, MD, MPH Medical Director Healthcare Quality Strategies, Inc. Daniel Moles, RN, BBA, MPS, LNHA President TRANSITION HealthCare Consultants 45

46 Discussion and Q&A You can use the chat Please submit your comments or questions to All Participants You can also use the phone Lines are open, please join the queue to add your comment or question 46

47 Thank you! 47

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