Balancing Healthcare Capacity with Back-Transfers

The COVID-19 global pandemic has revealed the unquestionable bravery and successes of healthcare workers across the country and around the world. It has also, however, uncovered strategic and operational weaknesses in healthcare systems. Consider, for example, the case of a rural U.S. healthcare facility with fewer than 15 patient beds and resources so limited that its only ventilator is a mobile unit designed for transport vehicle use. A patient was admitted with symptoms consistent with COVID-19, and his condition rapidly deteriorated. Ill-equipped to care for a patient who was expected to soon need intensive care, the hospital searched for a larger regional medical facility able to receive the patient. Bureaucratic hurdles and overwhelmed staff resulted in a delayed transfer, placing the patient at increased risk.

This scenario unfolded in a community less than 75 miles from a major state capital. In supporting Critical Access Hospital financial sustainability and quality improvement initiatives, our team recently heard this account directly from the healthcare workers involved.

With leaner staff levels and fewer intensive care beds, small local hospitals are less equipped than larger facilities to handle serious COVID-19 cases. This state of reduced readiness is leading to an increasing number of forward transfers. A forward transfer refers to the relocation of a patient from one healthcare facility to another, generally from a smaller facility to a larger provider that can offer more specialized care.

Yet, the beds and capacity available in smaller facilities in rural communities, namely Critical Access Hospitals, also have a crucial role to play in addressing the operational challenges brought by the pandemic. Through a less-common healthcare practice known as back-transfers, these hospitals can be utilized to treat more stable, non-COVID-19 patients and offer eventual recovery care. A back-transfer refers to the relocation of a patient from a large healthcare facility to a local community hospital, thereby releasing resources at larger hospitals to respond to the outbreak. This type of transfer is most likely to occur when a patient is near the end of an acute hospitalization; the patient then remains at the smaller community facility through the completion of his or her medical care. Back-transfer decisions are made based on an assessment of the continuation of patient care required and potential risks of relocation.

Back-transfers benefit the patient and both facilities involved. For patients with routine conditions that require more conventional clinical care, back-transfers offer the alternative of receiving care closer to home. Larger facilities use back-transfers with stable patients to make beds available for those in need of more specialized care. And smaller community hospitals, which generally have low patient volumes and significant profitability challenges, accept back-transfers to occupy beds.

Despite the potential to increase the efficiency and effectiveness of our holistic healthcare infrastructure, back-transfers are historically very rare. A 2017 study found that only 0.2 percent of eligible patients were back-transferred over a nine-year period. Among the barriers are health outcome concerns, a general lack of awareness, and systematic barriers, which include (but are not limited to) legal, logistical, and financial factors.

COVID-19 has placed a spotlight on the capacity challenges and resource shortages providers in the U.S. healthcare system now face. A more robust system of transfers with increased collaboration between small community hospitals and larger healthcare facilities presents an opportunity to better utilize the resources of a holistic healthcare system, which will help mitigate the impacts of the COVID-19 outbreak and strengthen our ability to respond to national health crises in the future. To facilitate more mutual transfers and increase collaboration, smaller local facilities should:

  • Formalize partnership agreements: Formally document partnerships with larger healthcare providers rather than operating under handshake agreements. Include logistical plans for patient transport. Documentation has been shown to increase the durability of the partnership and open the door for ongoing communication. Putting documented partnerships in place can also help increase the pace of back-transfers when the healthcare system is stressed or approaching maximum capacity.
  • Step up marketing efforts: Increase awareness of transfer offerings by highlighting specific positive experiences in local marketing campaigns targeted at members of your community. Back-transfers are driven in part by a patient’s desire to be treated or recover closer to home. Develop transfer offering overview materials for larger healthcare facilities in the region to distribute to patients in need of less acute recovery care.  
  • Leverage resources available through state departments of health and hospital networks: Engage with the Rural Health Network and your state department of health’s flex program coordinator. These public health experts regularly create content, such as templates for formalized agreements and toolkits for enhancing swing bed programs. They also create opportunities to connect with other healthcare facilities. Take advantage of these forums to share success stories and lessons learned. North Highland has supported these and similar efforts in our work with state departments of health across the country.

COVID-19 has been a catalyst for healthcare professionals to reevaluate longstanding assumptions and renew scrutiny of traditional hospital dynamics. As industry leaders begin to chart their future course, mutual transfers and increased collaboration between hospitals offer a promising approach to improve the efficiency and effectiveness of healthcare resources.