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Communication
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Continuity of care
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I don't think it breaks continuity, as long as the destination facility is in regular communication with the referring facility and communication.
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You need communication back and forth – standardized forms or processes between source and destination that everyone would use.
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Feedback
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I think creating a mechanism for timely feedback of the care of those patients will be important.
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Information Technology
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Centralized call center for all potential referrals to the main hospital.
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Install the same software program between hospitals so that all records can be transferred electronically. Then you can push the records back and forth between facilities.
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Education
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Develop and disseminate evidence of benefit
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Education of families and of physicians of the need to do this and the benefits to this would be a tremendous asset.
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System design
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Tier designation based on voluntary service level
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It would have to be a mandated criteria for keeping patients at certain seriousness of illness, in order to support a facility that would pass some agency's inspection.
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One solution would be to regionalize different strengths, if for instance, our hospital kept cardiac and CCU capabilities, and sent stroke patients to the other hospital.
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Broad stakeholder participation
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EVERYONE would have to be involved.
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Objective triage criteria
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Have criteria for what would warrant the patients being transferred. Therefore the doctor wouldn't feel like they failed.
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Reimbursement
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Feedback revenue to referring centers
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Reimbursement rates, so that the hospitals that are doing the transferring can have some reimbursement for the care of those patients.
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Reimburse the sending hospital for at least a portion of the care.
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Transfer patients back to source hospitals after improvement
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The patient is appropriately channeled back with the appropriate documentation.
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If people need to have acute rehab, it should be back at the primary unit where the family support is.
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