This project sought to: (1) identify evidence-based transfer protocols and other approaches/tools for effecting safe care transitions between community nursing facilities (NF) and CAHs focusing specifically on transitions through the emergency department (ED); (2) identify and assess strategies that Flex Programs, CAHs, and CAHs quality collaboratives are using to implement NF to hospital transfer tools and protocols; (3) recommend best practice tools and strategies; and (4) identify potential performance measures related to NF-CAH transfers. 

This project reviewed the peer-reviewed literature, reports and studies to identify evidence-based tools and protocols relevant for use by CAHs, other rural hospitals and their NF and EMS partners. In addition, the Flex Monitoring Team (FMT) conducted in-depth interviews with stakeholders from two to four of State Flex Program that have undertaken initiatives in these areas.