Transfers of Care: the Silent Natural Disaster

Apr 6, 2023

It was 11:20 pm.

I was digging out from traveling, catching up on emails in the stillness of the night.

A text alert came through. It was from a patient with metastatic cancer that had transferred to a hospice facility that evening. I assumed it was a regular check-in to say goodnight or “all good here.”

No dice.

“Do you have my updated list of my meds?”

How could a patient with advanced cancer that’s been hospitalized for two weeks and transferred to an in-patient hospice facility not have their health information follow them?!

I checked their patient portal.

Not only did the medications not follow the patient, the information in the portal was clearly wrong.

Discharge instructions stated: “No changes were made to your medications.”

I knew that was impossible, as moving from cancer treatment mode to supportive care meant a complete reevaluation of one’s medications.

The Medication List stated: “Your medication list is not available because the admission was too long ago.”

For the record, this patient’s admission was two weeks ago. Good grief.

Spent over an hour on the phone with the skilled nursing facility staff, going back and forth and comparing notes as they had little to no information on this very sick and terminally ill patient who was entering hospice.

Patients living with cancer at the end of their life should not have to worry about basic health information necessary for their care, like up-to-date medication lists following them.

Interoperability and access to information must be continuous through end-of-life care. This is non-negotiable.

The next day, this matter quickly escalated and proved to be a major care coordination issue as it became apparent that the discharge paperwork that followed the patient was missing information. More specifically, the discharge order was missing an order for hospice. The patient with end-stage cancer discharged to a skilled nursing facility (SNF) for hospice did not have hospice arranged or ready for their arrival.

The patient had no pain medications, equipment, or hospice care and instead was on the rehabilitation track at the SNF. The staff kept trying to get the patient ready for physical therapy when the patient was in excruciating pain and dying from cancer.

As the patient advocate, I was unable to get access to a copy of this discharge information. It was not posted in the patient portal. The social worker at the hospital referred me to medical records. The charge nurse never returned my message about producing a copy of the records. The nursing home also declined to provide a copy or show me the actual copy of the discharge paperwork that followed the patient.

When you are discharged from a hospital, it is important to ensure that you have a copy of your discharge paperwork before going to a skilled nursing facility. Here are the top 4 reasons why:

To ensure continuity of care: Your discharge paperwork provides information about your medical history, diagnosis, treatment, and medications. This information is crucial for the staff at the skilled nursing facility to provide continuity of care and avoid any gaps or errors in your treatment.
To prevent medication errors: Medication errors are common during transitions of care, such as from a hospital to a SNF. Having a copy of your discharge paperwork can help the skilled nursing facility staff ensure that you are receiving the correct medications in the correct dosages.
To prevent unnecessary tests and procedures: Having a copy of your discharge paperwork can help the SNF staff avoid repeating any tests or procedures that were already performed during your hospital stay. This can help reduce your healthcare costs and prevent unnecessary discomfort.
To ensure that your rights are protected: Your discharge paperwork includes important information about your rights as a patient, such as your right to privacy and your right to access your medical records. Having a copy of your discharge paperwork can help you advocate for your rights and ensure that they are being respected.

Having a copy of your discharge paperwork before going to a skilled nursing facility is essential for ensuring continuity of care, preventing medication errors, avoiding unnecessary tests and procedures, and protecting your rights as a patient. Make sure to ask your healthcare provider for a copy of your discharge paperwork before leaving the hospital, and keep it with you when you go to the SNF.

Transfers of Care: the Silent Natural Disaster

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