Streamlining Patient Admissions and Transfers: A Guide for Admission Liaisons

In a healthcare setting, effective communication and meticulous organization are key to ensuring seamless patient care, especially when managing admissions, transfers, and discharges. Whether you're coordinating with different departments, ensuring insurance verification, or managing equipment needs, every step is vital for patient safety and care continuity.

Here’s an actionable guide designed to aide hospital staff through the essential tasks involved in managing a patient’s transition to and from your care. Use this as a reference to stay organized, communicate effectively, and ensure all critical steps are completed on time.

1. Patient Information and Pre-Admission Details

Insurance Verification / Encounter: Ensure that the patient’s insurance information is verified, and check the Medicaid renewal date (if applicable). If there are any issues or delays, address them before proceeding.

Medical Clearance / DC Orders: Obtain and confirm medical clearance for the patient. Ensure discharge (DC) orders are updated and complete.

Room Assignment: Confirm the room number (e.g., Room 233). Verify important details such as proximity to a lift, elopement risks, shared room status, etc. Ensure the room is prepared for the patient's needs.

2. Communication with Key Staff Members

Transport Time: Confirm the transport time (e.g., 10:30 AM). Ensure that all necessary parties are notified in advance.

Contact Information: Have the attending MD’s phone number and the RN’s phone number available for quick communication.

House Sup / Charge RN: Notify the House Supervisor and Charge RN of the room number and transport time to ensure they are aware of the patient’s status.

3. Notifications and Digital Communication

Text Notification to Admitting Hospitalist: Send a text message to the admitting hospitalist with the following details: "New patient admitting to room [room number] at [time]. See chat for more info."

Epic Chat Setup: Include the hospitalist and PM&R (Physical Medicine and Rehabilitation) team in the Epic chat for continuous updates and communication. This ensures all clinical teams are aligned on the patient's needs.

Snapboard Updates: If transport is early (before 4:00 PM), ensure that the Snapboard is updated to reflect the patient's room, transport time, and any necessary therapy information (e.g., PT, OT, etc.).

Acceptance Note in Epic: Write the acceptance note in the chart using the designated format

4. Patient/Family Communication

Transfer Notification: Notify the patient and family about the transfer details, including expected time of arrival and room information. Make sure all questions are answered and any concerns are addressed.

Consent Forms: Ensure that the patient or caregiver has signed the consent form for transfer. Verify that the consent form is placed in the appropriate folder.

Weekend Admission Notification: For weekend admissions, notify the business office (e.g., Abi or Bree) to ensure the proper billing and administrative steps are completed.

5. Documentation and Authorization

PAS (Patient Admission System) Completion: Ensure that the PAS is completed, moved, updated, signed, and that the date of service (DOS) is correctly recorded.

Insurance Auth: If insurance authorization is needed, ensure the referral is added to the referral tracker. For verbal authorizations, communicate the dates, phone numbers, and fax details to the appropriate staff.

Auth Paperwork: Include a paper copy of the insurance authorization in the patient folder. For VA patients, ensure the VA authorization number is noted

6. Clinical Communication and Support

Case Management and Social Work: Any issues related to discharge planning, such as challenging cases or complex discharge needs, should be sent via secure chat to Case Management (CM) and Social Work (SW). This ensures early planning for safe discharge.

Dialysis Coordination: Check bed availability with the dialysis team if the patient requires dialysis during their stay. Communicate any special requirements via Teams chat.

Dietician Notification: If the patient requires tube feeds or other specific nutritional needs, notify the Dietician.

Special Equipment and Wound Care: Ensure that specialized equipment (e.g., bariatric bed, wound vac) is ordered and delivered as needed. Notify wound care teams if there are any ongoing treatment needs (e.g., ostomy care or wound vacs).

E-Sitter Availability: If the patient requires an e-sitter for safety reasons, ensure availability and appropriate staffing.

7. Referral and Outpatient Coordination

Outside Referral Checklist: Complete any necessary steps for external referrals, including communication with outpatient services. Ensure that MAR (Medication Administration Record) is sent to the pharmacy, and that any speech therapy needs (e.g., MBS/FEES) are communicated to SLP.

Outpatient Referrals for ANMC: Ensure that outpatient pharmacy referrals are completed as needed. If the patient is being transferred to ANMC (Alaska Native Medical Center), ensure that referral forms are submitted.

8. Discharge Planning and Documentation

Print Essential Documents: Print key documents for the MD, including orders, consult notes, progress notes, H&P (history and physical), discharge notes, operation notes, MAR, and therapy assessments.

Case Manager Discharge Summary: Print and review the discharge summary for the case manager. This should include follow-up MD appointments, ensuring the patient’s post-care needs are clear and actionable.

Front Desk Coordination: Deliver copies of the discharge summary, progress notes, therapy assessments, and MAR to the front desk for scanning into the system.

9. Final Steps and Coordination

Message to Front Desk: Send a message to the front desk to confirm that all necessary paperwork has been scanned and is in the patient’s digital file.

Coordination with External Providers: Ensure that any external providers (e.g., outpatient services, home care, specialists) are fully notified of the patient’s status and transfer details.

By following this comprehensive guide, hospital staff can streamline patient admissions, transfers, and discharges, reducing the likelihood of missed steps or delays. This ensures the best possible care for patients and efficient communication across all involved teams. When every detail is addressed, from insurance verification to equipment requests, the transition is smoother, and both patient and family experience higher-quality, coordinated care.