How we support patient transfers

With the goal of replacing the outmoded institutional model of patient care, the Riverview Hospital Redevelopment Project calls for the development of tertiary psychiatric “replacement” beds in each region of the province. To that end, each regional health authority is planning a range of tertiary residential, rehabilitation and acute care beds to meet the needs of their clients who are currently being cared for at Riverview, and future clients who may need tertiary care services.

The development of these services is based on the expectation that the clinical and environmental needs of each of these patient populations will be met in the new care settings. This is the responsibility of the regional health authorities, each of whom has a performance agreement with the Ministry of Health. As an agency of the Provincial Health Services Authority, Riverview Hospital works closely with both the ministry and the regional health authorities to implement these plans.

Community transfer - key activities

Riverview Hospital (RVH) provides:

• clinical and administrative information to assist health authorities in their planning for RVH replacement beds and services (information includes patient needs assessments, patient profiles, special population needs, utilization data, staffing levels and mix, facility and equipment requirements);
• review of service delivery plans to ensure that patients will be provided equal or better care;
• Meetings with health authority representatives, clinical presentation and feedback to assist with the development of RVH replacement beds;
• site visits to new facilities to provide feedback;
• a bed transfer schedule based on health authority readiness to provide tertiary psychiatric services;
• coordination of the transfer of patients, followup as required and evaluation of the transfer process;
• transfer funding from PHSA to the health authority once bed replacement and services are in place, and patients have been transferred.

Patient transition process

As new beds are developed in the regional health authorities, individual planning occurs for each patient who will be transferred. Prior to patient transfers occurring, service delivery plans (functional plan) are reviewed and facilities are visited by clinically experienced representatives from Riverview Hospital. Involuntary patients are transferred under section 35 of the Mental Health Act. Voluntary patients who wish to continue receiving care in the new facility are transferred under Section 36 of the Mental Health Act to the new facility.

Identification of patients suitable for transfer

Once health authority plans are finalized, RVH begins to develop a transfer list of patients for each new facility.

Patients who originate from the health authority where the new facility is located have first priority if they require the level of service developed.

Patients who have family or significant others in the health authority, have a desire to move to that health authority, and whose needs can be met by the new service, are also included if beds are available.
Patients who have no family may also be included if they have a desire to move to that health authority and adequate new beds are available.
The identification of patients suitable for transfer is coordinated by the RVH Community Transfers Department, in conjunction with RVH clinical teams (these include the patient, family, and significant others in their determination as to which region the patient prefers).

Community Transfers Department notifies the public trustee of potential transfers for patients who are not in contact with any family members.

Once patients are confirmed for transfer, patients and families are notified. Individual transition planning occurs.

Patient transition planning

Pre-transfer clinical documentation is collated and sent to the health authority.

Transition plans include:

• patient demographics
• admission history
• social worker reports
• diagnosis
• current integrated plan of care
• nursing care plan
• current medication and history
• activities of daily living and rehab needs
• key patient needs and considerations
• psychosocial history
• discharge summaries
• involved family contacts and information
• transfer date and details
• copies of relevant chart documentation
• RVH contact numbers
• New facility contact information

Patient transfer involves arranging timing (date and number of patients transferred), clinical escort/support, transport vehicle or flight, and orientation time at the facility for clinical staff to meet with staff at the facility.

Follow-up, evaluation and tracking

Clinical follow-up is provided as required by RVH clinical staff via teleconference and/or site visits. Clinical support will be provided if needed.

PHSA/Riverview representative meets with representatives from the receiving health authority, RVH clinical teams and facility staff to evaluate the transfer process. Feedback is incorporated into revised transition planning.