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Driving Progress in Patient Transfers to Expand Access to Care

5 minute read
A medical professional in blue scrubs pushes a patient on a hospital stretcher through a brightly lit corridor. The patient is covered with a blanket and wears a surgical cap.

From all corners of New England, hospitals send patients to Mass General Brigham’s academic medical centers (AMCs) to receive the complex, high-level care that our expert teams are equipped to provide.

From Aroostook County at the northern tip of Maine, an eight-hour ambulance ride away, and rural Vermont to more-densely populated local areas, patients are transferred from within and outside our system to Massachusetts General Hospital and Brigham and Women’s Hospital for specialized care. But what happens once they are stabilized and recovering? When they still require inpatient care but not at the same high level? 

That is the focus of a small team of case managers in Mass General Brigham’s Patient Transfer and Access Center who facilitate repatriation transfers, ensuring that patients at our AMCs return to their original, referring hospitals as soon as it is clinically appropriate. This essential work is helping to alleviate capacity pressures at our AMCs and open up beds for the next patients who need them.

The team’s proactive involvement, from the moment a transfer request is received throughout a patient’s care at one of our AMCs, is making a difference. Mass General Brigham saw a 34 percent increase in repatriation transfers from fiscal year 2023 to fiscal year 2025.

“These are very skilled clinicians who can tease apart the complexity that can be involved in these cases. It’s not just medical complexity, there are sometimes social, financial and legal complexities as well,” said Kim Barry, RN, MS, FACHE, vice president of Enterprise Care Continuum for Mass General Brigham. “They are always thinking two and three steps ahead, regularly communicating with our AMC care teams and working to advance patients along a care path that enables them to recover closer to home.”

Two ambulances are parked near the entrance of a Mass General center on a winter day with snow visible on the ground.

Proactive communication and coordination

Case managers Kimberly Fahey, RN, Annie Pitt, RN, and Amelia Capone, RN, screen transfer requests received by the Patient Transfer and Access Center to ensure incoming patients are properly placed, receiving the right level of care at the right location within Mass General Brigham. They participate in daily meetings with colleagues from across the system to monitor the capacity status of every Mass General Brigham hospital and identify opportunities to transfer patients either within our system or back to a referring hospital outside of it.

“We track patients who have come into our AMCs and regularly review their charts throughout their care,” Fahey said. “If a patient’s care team hasn’t contacted us, we’ll reach out to them to see where things stand and whether or not a patient we’ve been following is a candidate for transfer.”

If a patient is stable enough to be transferred, either Fahey, Pitt, or Capone work with the hospital that the patient is returning to, either its transfer center staff or nursing supervisors, to ensure that there is an available bed and the patient’s clinical needs can be met. They then coordinate transportation, provided by either Mass General Brigham Ambulance Services or the system’s contracted ambulance provider.

For the patient from Aroostook County, Capone worked with the team at Brigham and Women’s Hospital to confirm that the patient’s oxygen level was stable enough for transport and made sure the receiving team at Cary Medical Center in Maine understood the patient’s condition and the care they would need to provide.

“The patient had a complex hospitalization. He had been intubated but had recovered and was receiving IV pain medication,” Capone said. “The patient still required inpatient care and eventually a transfer to a rehabilitation facility, but he had reached the point where he was better served to be closer to home, his family and local support resources,” Capone said.

Coordinating the return of patients to their communities, whether they are located across the state, region and, in some cases, the country and beyond to international locations, requires collaboration with key stakeholders to manage complicated logistics and ensure safe transport and care. Essential to Fahey, Pitt, and Capone’s roles is effective communication and relationship building, both with internal teams and hospitals outside our system.

“Fostering relationships within and outside Mass General Brigham enables the collaboration and partnership that keeps patients moving on a positive track and helps support their recovery,” Barry said.