Maine Rural Health Research Center

The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article, authored by research staff at the Maine Rural Health Research Center, USM Muskie School, examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access.

The authors review ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models, and analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. The authors propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers, including adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.

Suggested Citation: Talbot, J. A., Coburn, A., Croll, Z. and Ziller, E. (2013), Rural Considerations in Establishing Network Adequacy Standards for Qualified Health Plans in State and Regional Health Insurance Exchanges. The Journal of Rural Health. doi: 10.1111/jrh.12012

Research has shown that essential information is often missing during transfer of nursing facility residents to the ED, and communication problems between nursing facilities an EDs are one of the most cited barriers to providing quality patient care.  Tools, such as tranfer forms and checklists, that improve communication between settings of care help improve patient safety and quality of care. 

This Policy Brief includes an appendix of transfer forms from 11 organizations.

Key Findings:

• Transfers to the hospital emergency department (ED) are common for many nursing facility (NF) residents, with over 25% experiencing at least one ED visit annually, and many encountering repeat visits.

• Communication issues, including incomplete information during transfer, impact clinical care of the elderly NF resident transferred to the ED.

• Several studies strongly recommend the use of standardized transfer forms as a way of improving communication, which ultimately improves patient safety and quality of care. However, standardized transfer forms, in and of themselves, are not sufficient to solve communication issues between the sites of care (NF, EMS, ED).

• The establishment of ongoing relationships between hospital, EMS, and nursing facility staff help facilitate effective communication regarding patient needs during the transfer process and encourage the development of a systems approach to the transition of care.

Why are standardized transfer forms helpful?

For Nursing Facilities: they help facilitate accurate exchange of information, reduce potentially avoidable hospitalizations, and provide a record of the patient's condition upon return.

For Nursing Facility residents: they help to increase the efficiency and effectiveness of transfer and treatment and may help the resident avoid additional health complications and emotional trauma.

For EMS: they provide the needed information to treat the patient en route and facilitate an accurate and comprehensive handoff report to the hospital.

For Hospitals: they help facilitate effective assessment and treatment of the patient in the ED, minimizes time spent in the ED, and reduces unnecessary admissions.

For Policymakers: to help reduce costs associated with unnecessary hospitalizations and longer ED lengths of stay.

Suggested citation: Pearson KB, Coburn AF. Emergency Transfers of the Elderly From Nursing Facilities to Critical Access Hospitals: Opportunities for Improving Patient Safety and Quality. (Policy Brief #32).  Portland, ME: Flex Monitoring Team; January 2013.

For more information on this study, please contact Karen Pearson at karenp@usm.maine.edu