Transfer
What counts as a transfer, the two-day deadline, and the choice between transfer with and without discharge.
A transfer is what you complete when a patient is admitted to an inpatient facility. It is almost always discovered second-hand — from a family member, a voicemail, or an empty house — which is why the deadline is easy to miss.
What counts
An admission to an inpatient facility for 24 hours or longer, for reasons other than diagnostic testing.
| Counts as a transfer | Does not |
|---|---|
| Hospital admission, 24 hours or more | Emergency department visit, discharged same day |
| Admission to a rehab facility | Overnight stay purely for a diagnostic test |
| Admission to a skilled nursing facility | Outpatient surgery with same-day discharge |
| Admission to a psychiatric unit | A stay in a facility that is the patient's home |
Observation status is the awkward one. What matters is whether the patient was admitted as an inpatient for 24 hours or more — not what the wristband said. If you cannot tell, ask; do not guess.
The deadline
The transfer assessment is completed within 2 calendar days of learning of the transfer.
Not two days from the admission — two days from when the agency found out. Which means the moment you find out, it is your job to make sure the agency knows that day.
Transfer with or without discharge
This is the decision that trips people up. You are choosing what happens to the episode.
Transfer without discharge
The patient is expected to come home and resume care with us. The episode stays open. When they get home you complete a resumption of care — see Resumption of Care (ROC).
This is the usual choice for a short admission where the patient is coming back.
Transfer with discharge
The patient is not returning to us — they are going to a facility long-term, transferring to another agency, entering hospice, or the family has decided differently. The episode closes.
If you are unsure which applies, ask your Field Supervisor before you complete it. Choosing wrong creates a correction, and corrections to OASIS are painful.
What to do when you find out
- Confirm it. Where is the patient, which facility, what date did they go in, and were they admitted or held for observation?
- Tell the office the same day. The two-day clock is running.
- Find out why. The reason for admission is clinical information about the care we were providing.
- Notify the other disciplines on the case, and the scheduler.
- Complete the transfer OASIS within two days.
- Notify the physician if they do not already know.
The part worth doing properly
Every transfer to hospital is a patient our care did not keep at home. Some were unavoidable. Many were not.
Before you close it out, ask honestly:
- Were there signs at the last visit that we did not act on?
- Was the frequency right?
- Had teaching been retained, or only delivered?
- Did the patient know what would make them call, and did they call?
- Was there a medication problem?
Write what you find. Acute care hospitalization is a publicly reported outcome measure, and more importantly it is the clearest feedback available on whether the episode was working.
Bring it to case conference — see The Care Team and Who Does What.
Where transfers go wrong
- Nobody found out for a week. A missed visit was recorded as "patient not home" and never followed up. Call the patient the same day.
- Transfer chosen with discharge when the patient came home three days later — now there is a discharge to undo and a new SOC to justify.
- Observation stay treated as an admission, or the reverse.
- The other disciplines kept visiting because nobody told them.