Background: Large academic medical centers (AMCs) facing emergency department (ED) and inpatient capacity constraints are increasingly partnering with community hospitals to care for appropriate lower-acuity patients. Because regulations require patient assent for interfacility transfers, standardizing this process across a large group of hospitalists has proven difficult. Patients frequently decline transfer due to uncertainty about community hospital capabilities, prior negative experiences, perceived financial risk, or concerns about a conflict of interest from the assenting physician. Consequently, assent rates at urban AMCs remain low.
Purpose: To improve interfacility transfer assent rates by training a smaller group of case managers (CMs) to use standardized scripts and educational materials when obtaining patient assent.
Description: In collaboration with hospital medicine, legal/regulatory, patient relations, and transitions of care teams, a standardized two-part script was developed: 1) to set expectations during the CM’s initial encounter, and 2) to guide the assent conversation. An accompanying FAQ, informational pamphlet, and posters about the community hospital were also created. Three daytime ED CMs were trained on these materials.Before implementation, assent was obtained by hospitalists and tracked via physician notes, with success rates ranging from 30–40%. Hospitalists reported internal conflict during assent discussions and competing clinical demands that limited consistency. During the pilot phase, CMs achieved an assent success rate of 86%. Possible contributing factors included earlier patient priming through standardized messaging, greater consistency and expertise among a smaller group of assenting CMs, and reduced perception of conflict of interest. Both hospitalists and CMs reported improved satisfaction with the new process.
Conclusions: At a large urban AMC, trained case managers achieved higher interfacility transfer assent rates than hospitalists. Expansion of this CM-led process to nighttime admissions and eligible inpatients is planned.
