Improving transitions: efficacy of a transfer form to communicate patients' wishes

The objective of this study was to test the efficacy of a standardized form used during transfers between long-term care facilities (LTCFs) and the acute care setting. The intervention consisted of development and implementation of the transfer form and education about its use. Charts from 26 LTCFs and 1 acute care hospital were reviewed at 1 and 6 months prior to initiation of the transfer form (2007) and at 1 and 6 months after initiation of the transfer form (2008); 210 patient charts were reviewed in 2007 and 172 in 2008. There was 79% concordance between documented LTCF advance directives (ADs) and hospital ADs in 2008-an increase from 66.6% in 2007 (P = .038). Inpatient hospice/palliative care admissions rose from 1.5% in 2007 to 7.7% in 2009 (P = .015). The standardized transfer form improved communication of ADs between LTCFs and the hospital. Secondarily, it may have increased admissions to the acute palliative care unit.