Document Type

Capstone Experience

Graduation Date

5-2025

Degree Name

Master of Public Health

Department

Health Promotion

First Committee Member

Dejun Su, PhD

Second Committee Member

Trina White, DrPH, MBA, MSPT, FACHE, FACMPE

Third Committee Member

Tabatha Matthias, DO, MBA, FACP, FHM

Abstract

Background: Bed capacity challenges at large academic medical centers delay the transfer of rural patients, negatively impacting their safety and quality of care. Repatriating inter-hospital transfer (IHT) patients to referral facilities upon completing specialized care can improve tertiary hospital bed capacity and community hospital financial sustainability.

Objectives: This project aims to identify the barriers and facilitators to successful IHT repatriation and the process and outcome variables influenced by the Nebraska Medical Center’s reverse transfer program.

Study Design: A retrospective observational cohort study was conducted to identify barriers and facilitators of NM’s IHT repatriation program.

Methods: Descriptive and comparative analyses of quantitative data collected from two repatriation-eligible IHT patient cohorts, i.e., Group 1 patients were successfully transferred back to the referring hospital upon conclusion of specialized care at NM, and Group 2 patients were not successfully repatriated, highlighted key barriers and facilitators of successful repatriation.

Results: 51 patients were repatriated to their original facilities between June 2022 and December 2024, resulting in 609 bed days saved based on the additional length of stay at the referral facility after repatriation from Nebraska Medical Center and $886,386 in total estimated cost savings based on the number of bed days saved. The combination of an AI screening tool introduced in June 2024 and a nurse-driven deep dive evaluation of IHT repatriation candidacy resulted in the identification of 92 potential candidates between June and December 2024. Of these 92 potential reverse transfer candidates, 17 were successfully repatriated to their home facility (18.5% success rate), and 75 did not repatriate. The top two reasons for unsuccessful reverse transfer were (1) ineligibility because the patient’s expected discharge was in 48 hours or less and/or they no longer required an acute inpatient care level (N=34, 45.3%) and (2) referral facility denial (N=17, 22.7%). Reasons for referral facility denial of a reverse transfer request include: (1) the patient’s insurance provider (not accepting Medicare advantage patients); (2) inappropriate level of care, either too medically unstable (e.g., high oxygen needs) or medically stable and awaiting placement in a post-acute care facility; (3) lack of resources such as specific subspecialty services, nursing staff capacity, and one facility had a scheduled power outage; (4) Lack of available beds at the referral facility; and (5) Facility not accepting lateral transfers. Statistical analyses revealed that the key factors driving disparate reverse transfer outcomes are gender, rural-urban commuting area (RUCA) score, area deprivation index (ADI), referral facility distance, and bed capacity. Variables associated with a higher likelihood of successful reverse transfer are male gender, patients from less rural areas and higher socioeconomic neighborhoods, patients transferred from farther away, and referral facilities with higher bed capacity.

Conclusion: Systematically identifying facilitators and barriers of NM’s IHT repatriation process provided insights on ways to improve repatriation through investment in full-time employees whose sole job responsibilities support a 24-hour IHT repatriation program, earlier initiation of the IHT repatriation process before the patient has completed their specialized tertiary care, limited NRC staff prioritization of repatriation attempts with larger referral hospitals located farther away (e.g., those with a minimum of 200 beds and a distance of > 100 miles away), ongoing IHT repatriation program evaluation to understand and mitigate the key drivers of disparate repatriation outcomes, and future qualitative data collection among NM and referral facility stakeholders participating in the IHT repatriation program to understand better and address the factors leading to reverse transfer failure and reverse transfer request denial. Employing these improvements can lead to enhanced repatriation outcomes, IHT patient flow, tertiary hospital bed capacity, stronger community and tertiary hospital partnerships, and increased rural hospital sustainability.

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