What is the proper procedure for referring a patient to long-term care?

Proper Procedure for Referring a Patient to Long-Term Care

The proper procedure for referring a patient to long-term care requires a comprehensive initial assessment, preparation of appropriate documentation, and coordination with the receiving facility to ensure continuity of care and optimal patient outcomes. 1

Initial Assessment and Documentation

Medical Assessment

• Complete a thorough assessment of the patient's:
  • Functional status (physical, cognitive, and communication abilities)
  • Medical conditions requiring ongoing management
  • Current medications and treatment plans
  • Rehabilitation needs and goals 1
• Document any advance directives or goals of care discussions 1
• Include assessment of physical, functional, emotional, cognitive, and social needs 1

Required Documentation

1. Detailed discharge summary with comprehensive care plan 1
2. Complete medication list with administration schedules
3. Recent laboratory and diagnostic test results
4. Advance directives and goals of care documentation 1
5. Rehabilitation and therapy recommendations
6. Accessibility requirements and equipment needs 1

Coordination with Long-Term Care Facility

Communication Process

1. Contact the LTC facility to determine their specific admission requirements
2. Share the discharge summary and care plan with the receiving facility 1
3. Arrange for direct communication between sending and receiving healthcare providers
4. Ensure alignment of assessment processes with the receiving facility's protocols (e.g., RAI-MDS 2.0) 1

Special Considerations

For Patients with Diabetes

• Include individualized glycemic goals based on clinical and functional status 1
• Document diabetes education needs for LTC staff 1
• Specify monitoring protocols and hypoglycemia prevention strategies 1
• Consider simplifying insulin regimens to reduce hypoglycemia risk 1

For Patients with Stroke

• Include ongoing rehabilitation goals and recommended services 1
• Document communication capacity and speech therapy needs 1
• Specify physical and occupational therapy requirements 1

For Patients Requiring Infection Management

• Document any ongoing infections and treatment plans 1
• Include information about recent antimicrobial therapy
• Note any infection control precautions needed 1

Patient and Family Involvement

1. Discuss LTC options with patient and family before referral 2
2. Provide education about the transition process and what to expect
3. Include patient/family in care planning discussions 1
4. Address any concerns about the transition
5. Ensure understanding of financial aspects and insurance coverage

Common Pitfalls to Avoid

• Inadequate documentation: Incomplete records lead to care discontinuity and potential adverse events
• Poor communication: Failure to directly communicate with receiving facility staff
• Insufficient advance planning: Rushing the transition process without adequate preparation
• Neglecting patient/family preferences: Not involving them in decision-making
• Overlooking rehabilitation needs: Failing to specify ongoing therapy requirements 1
• Ignoring advance directives: Not documenting end-of-life preferences 1

Follow-up Responsibilities

1. Confirm successful transition and receipt of all documentation
2. Address any questions from the receiving facility
3. Schedule follow-up assessment if needed
4. Ensure continuity of specialized services (e.g., rehabilitation) 1
5. Document the completed referral process in the patient's medical record

By following this structured approach to long-term care referrals, healthcare providers can ensure a smooth transition that maintains continuity of care and optimizes patient outcomes while reducing the risk of adverse events during the transition process.