For all the expansion of hospital medicine beyond its original focus on the hospital floor—incorporating extensivists, skilled-nursing-facility-ists, laborists, nocturnists, etc.—an essential role in the realms of interfacility triage and transfer management is starting to get its deserved attention from the field.1-3
Hospital interfacility transfers have been around for a long time, traditionally handled ad hoc with a few phone calls between on-duty physicians. But as the need for transfers has increased, along with demands for quality review and clinical safety, attention to capacity and throughput, and calls for more standardized best practices, some hospitals have responded by creating transfer or command centers staffed with triage staff.
In some facilities, hospitalists have filled the role of clinical triage or transfer medicine specialist. In others, they are crucially embedded as gatekeepers at the decision points of patient admissions and transfers, and thus are deeply involved in their hospitals’ transfer processes. Their clinical judgment directly impacts hospital efficiency, patient safety, and resource utilization.
The landscape of hospital transfers has changed over the past several years, in response to increased demands for finite hospital resources, said Joyce Kim, MD, associate chief of clinical affairs in the division of hospital medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “When we think of transfer medicine, we think about patients who may have certain clinical needs that can’t be met at their current hospital.” That hospital needs to transfer the patient to a different setting, but the receiving hospital needs essential data to facilitate the move.
Dr. Kim
Dr. Van Calcar
Dr. Kim and her colleague Sara Van Calcar, MD, associate section chief of hospital medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, have presented on this topic at two recent SHM Converge conferences. SHM also has a Special Interest Group on interhospital transfers, led by field experts such as vice chair Sandeep Pagali, MD, MPH, of the Mayo Clinic in Rochester, Minn.
At Penn, there is a new role called medicine triage attending doctor, and Drs. Kim and Van Calcar are involved in day-to-day clinical operations for its transfer management program. Penn established an admissions or capacity-management transfer center serving its four downtown Philadelphia hospitals, staffed by medical assistants, capacity-management nurses, and other staff sitting together in an office suite.
Fifteen or so of the Penn system’s 50-plus hospitalists have taken on the medicine-triage-attending-doctor role, typically in shifts of seven days on from 8 a.m. to 5:30 p.m. But they don’t spend their time physically in the transfer center because they need to be mobile in the hospital, particularly the emergency department (ED), where most of the action happens. There they meet the patients, triage them, and guide them to the appropriate level of care.
When on the triage shift, they are focused on inflow into the ED and keeping an eye on what’s happening in the outside hospitals wanting to transfer patients, Dr. Kim said. “We’re trying to be more attentive to the patient list and not let it stagnate. And throughout the process, we’ve become closer partners with our EDs. I think we have come to understand each other a lot better—why things are the way they are and why we experience strain,” she said.
Transfers are no longer just about rural to urban or small to bigger hospitals, as the field becomes more nuanced, Dr. Kim added. “There are now very specialized medical services and procedures that even academic hospitals may not have, requiring patients to be moved elsewhere to receive that specialized care,” she said. Interfacility transfers can also be a useful mechanism for load leveling across the system, sending patients to a hospital that has more bed availability.
Managing Capacity
Dr. Pizanis
For Charles Pizanis, MD, FHM, director of the hospitalist training track in the department of internal medicine at the University of New Mexico (UNM) School of Medicine in Albuquerque, N.M., such capacity management is as much of a focus as transferring patients into his hospital. “We, thankfully, at UNM, have most of the services that most patients need,” while other facilities, such as smaller hospitals, may not.
“Then the next question is: Do we have the beds? If the patient is of a lower acuity, and we know that another hospital has the services the patient needs and our hospital is full, the name of the game in our community is capacity,” he said. “I know this is a very common crisis across the country. So, yes, we’re always thinking about it, and it’s always happening, because we are always full.”
Interfacility transfers require logistics, planning, and collaboration with nearby hospitals, Dr. Pizanis said. “There has to be buy-in from all the parties at that level. Establishment of protocols, putting in personnel that are familiar with the processes and able to help manage the transfers, all that stuff is essential for referrals from outside of our health system.” There is also ongoing communication with patients and families about the process, obtaining their consent. “We have a separate call center staffed by our emergency medicine group,” he said.
“And the other bit of it is having a good understanding of what services are available at each institution to identify the patient populations that could best proceed with a transfer. We’ve worked with certain specialty services at certain hospitals, for instance an affiliate hospital in our health system that has an outstanding orthopedic surgical center of excellence,” Dr. Pizanis said.
“The majority of our transfers out of our hospital go to our system’s affiliate hospitals, where we share a lot of the same leadership. That makes things a little more streamlined.” He said one of the silver linings of the COVID-19 pandemic was the development of stronger relationships for capacity management—with the help of a statewide hospital-capacity-management center. “That was pivotal for establishing the pathways that in many ways are still here.”
A New Approach
Dr. Iyer
“I think with our triage role, at least within my health system, it’s definitely something new that we’re doing,” said Sonali Iyer, MD, a hospitalist at University of California-Irvine (UCI) Health in Irvine, Calif. “Our transfer center has been present in our hospital for several years, but in the last two years we had a new director come in, with extensive knowledge of how transfers are supposed to work and how to make a hospital more accessible to patients who need a higher level of care,” Dr. Iyer said. “We’ve seen a significant change in the way we’re able to accept patients and how quickly we’re able to bring them into our hospital system.”
Dr. Iyer is in a dyad partnership with UCI’s director for clinical care operations, who also directs capacity management and the transfer center, with oversight over key areas to make sure the systems are running efficiently. There are three specific service lines that the transfer center does not manage. They are direct transfers from emergency department to emergency department, with their very specific criteria; the burn center, which manages its own transfers; and cases of imminent labor and delivery.
UCI’s transfer center is staffed by intensive care unit-trained nurses who have extensive experience being able to interpret the information in the chart, along with case management issues, Dr. Iyer said. “But they don’t make the final decision of which patients will transfer or not. That still goes to the specific physician in the specialty that the patient is seeking.” If the patient needs an ear, nose, and throat consult, for example, or surgery, the case goes to that physician to review, after transfer-center staff has quickly reviewed the chart for red flags, such as the level of care that is required and how quickly the patient can transfer over.
“There is an assessment of the patient’s insurance to see whether that may become a barrier, knowing whether we would need a letter of agreement from that payer for the patient to even come to our hospital,” Dr. Iyer said. “There is a screening tool that we use as well for certain types of conditions or other patient factors that might make it harder for our hospital to be able to later discharge that patient or that may lead to other issues while they are here. This screening tool helps determine if additional review is required by one of the physician advisors before presenting the patient to the specialist.”
Dr. Iyer is the capacity command center medical director, responsible for providing physician oversight for transfer center activities and bed placement coordination with the hospital system while retaining clinical responsibilities as a hospitalist. “We have our main academic center, with about 400 beds, and then we have five other hospitals that we work with that are part of our health system.”
Her role also includes screening all of the boarders in the emergency room to see whether or not they meet criteria for inter-location transfer to an inpatient bed at one of the system’s community site locations. “That provides several benefits, as we can quickly move the patient into a more healing inpatient environment that can provide the same clinical services while creating more capacity for the emergency room.”
Transfer Challenges
Mr. Facklam
Not all specialized transfer programs employ hospitalists or other clinicians. “When we did our first literature review around triage, we found that people consider these important skills, but not that many programs offer specialized triage training for residents,” Dr. Van Calcar noted. Patients also get discharged from the hospital to home, hospital at home, home care, or a subacute rehabilitation facility. There may be procedure-only transfers that don’t require an assigned bed because the patient will be going back to the initiating hospital on the same day. And patients who are on an observation level of care in the emergency room may need the attention of the transfer specialists.
Hospital medicine nurse practitioner Arnold Facklam, NP, FHM, has been involved in interfacility transport at a number of institutions, working in both adult and pediatric care, although he’s not involved with transfer work in his new position, doing cross-coverage as an APRN nocturnist at Sarasota Memorial First Physicians Group in Sarasota, Fla.
“When I was doing pediatrics strictly, the pediatric transfer was pretty much one way, to the tertiary center for pediatric patients. They have their own team. They get the calls from outlying facilities, and then they typically send out their team to pick up the pediatric patients and bring them back,” he explained.
Even if a large health system has developed a command or transfer center, if it has a pediatric hospital or department, that group often will do its own transport and not look to the system’s command center, Mr. Facklam said. When a child is being transported by the pediatric hospital’s transport team, it’s generally urgent and serious.4
In many cases, the referring hospital doesn’t have pediatric specialists or feel comfortable managing pediatric patients. So it relies on the pediatric team to determine level of service and mode of transport. Some pediatric services may use a nurse-led pediatric illness severity scoring tool such as the Pediatric Early Warning Score to identify patients at risk of clinical deterioration.
For Mr. Facklam, the question of who assumes responsibility for a patient in transit is critically important and could have big implications for staff and their institutions. Two or more institutions may be involved in a conversation about what’s the best option for a given patient, but often the sending facility retains legal responsibility until the patient reaches the receiving hospital’s emergency department.
When you add transport across significant distances, or additional services such as air transport, it gets even more complicated, he said. “I’ve been involved in situations where they were planning to send the patient with just a paramedic and EMT in the ambulance or helicopter when the clinical need was greater than they could handle.”
Transfer teams need to keep aware of the Emergency Medical Treatment and Active Labor Act (EMTALA), among other regulatory requirements.5 EMTALA, which says that anyone who enters a hospital emergency department must receive necessary emergency care, also applies to patient transfer requests originating in an emergency room, unless there is no capacity available at the accepting facility. Understanding the nuances of EMTALA is crucial to interfacility transfer management.
An article in the April 2025 issue of The Hospitalist recommended the use of a standardized form, template, or questionnaire to identify the need for transfer and ensure smooth handoff.6 It doesn’t require a physician to capture the standardized information, but the hospitalist’s role is to quickly ascertain and summarize the medical information that the receiving team will need, such as code status and interventions performed.
Other keys to effective interfacility transfer management include access to real-time bed data, essential to good decision-making. Increasingly, AI is helping to enable forecasting of what’s going to happen and potential surge capacity. A recorded phone line is a standard feature for transfer programs, providing an accurate record of conversations made during the transfer process.
Multi-Screen Data Display
Dr. Poonacha
Thejaswi Poonacha, MD, MBA, FACP, SFHM, a hospitalist at Emory Johns Creek Hospital in Johns Creek, Ga., recently relocated from the University of Minnesota. Both systems have used transfer centers staffed with multiple staff in different roles to manage a high volume of calls, he said. In Minneapolis, the medical director was called the System Operations Center, or doctor of the day, he said. At Emory, there is a medical director (called the Medical Officer of the Day) who oversees the transfer process. Other systems may have an equivalent for that, and it could be a hospitalist, who would be well-suited to that function, Dr. Poonacha said.
The transfer center at Emory is located at a satellite site that houses other administrative functions. The center has a multi-screen live data display and runs real-time tallies of available beds, providing minute-by-minute knowledge of where discharges are happening, where the new patients are going within the hospital, and where ED patients are going to, he said.
“Multiple people are fielding the high volume of calls,” and they are called transfer specialists. But they are joined by staff focused on utilization management to make sure this is the best utilization of the service, plus compliance, risk, and bed management. “And ultimately, once all of the planning becomes clear, the hospitalist comes in to accept the patient. The accepting or admitting hospitalist gets all the details that are needed, and when ready, the system sets up the call,” Dr. Poonacha said.
A Critical Clinical Role
Dr. Kim called triage and transfer a critical clinical role for hospital medicine. “We’re not only impacting the ability of patients to get their care quickly, but it also has a positive downstream ripple effect to create more capacity for other patients down the line,” she said. “I also think you need to have someone who can communicate effectively, get along with others, and collaborate, with a broad understanding of how the system operates and the interconnectedness of the different service lines in the hospital and how we all work together to support each other,” she said.
“It takes a lot of creativity, a lot of problem-solving and collaboration, which we’ve tried to integrate into a specialized system. We have 11 service lines, which can make things complex sometimes. So you need someone who really knows how things operate, and has the experience in using that system and collaborating with other groups.”
Drs. Kim and Van Calcar have worked hard to make the business case that improving transfer functions, for example avoiding observation-level admissions to inpatient beds, can increase revenue generated from higher acuity admissions while improving physician and patient satisfaction and quality of care. They say it boils down to opportunity costs.
“We think hospitalists can excel in this role, and it can make financial sense for a hospital to have dedicated hospitalists doing only triage, to make sure that patients get to the right service, the right bed, the right level of care within their hospital, but also at the right hospital,” Dr. Van Calcar said. It takes time to lay the groundwork to make the arguments that this is a valuable service.
Dr. Pizanis said hospitalists in his group at UNM rotate through the job of accepting physician of the day, receiving calls from outside referring hospitals, and then having the discussion to establish whether or not the patient is in need of transfer. “Some doctors, including myself, really love this role. This is my bread and butter, my passion in medicine. So I do it on a majority of my hospital shifts,” he said.
“I enjoy the multispecialty collaborations that can happen very quickly. Our emergency medicine group and our hospitalist group are close, and I’ve enjoyed working across the aisle in that regard,” he added. “I also like talking to people outside of our hospital, talking with other doctors and other health care team members.”
Dr. Pizanis said bed capacity issues are directly connected to quality of patient care, such that it has become almost a mission for him. “If we’re effectively navigating hospital capacity, we can help our community in the right way, in many cases making a difference for individual patients. If a patient is coming to our hospital and would have to wait 24 or 36 hours for an inpatient bed, but could be safely cared for in another facility that could admit them within two hours, helping to facilitate that admission for the patient is a rewarding role for me. And it’s really fun.”
Larry Beresford is an Oakland, Calif.-based freelance medical journalist.
References
- Freeman GA. The extensivist model. Health Leaders website. https://www.healthleadersmedia.com/strategy/extensivist-model. Published September 15, 2016. Accessed September 16, 2026.
- First Docs. What is a SNFist? Definitions, benefits, and impact. First Docs blog. https://firstdocs.com/blog/what-is-a-snfist/. Accessed September 16, 2026.
- Atallah F. What is a laborist? Am J Obstet Gynecol. 2013;208(5):418. https://doi.org/10.1016/j.ajog.2013.01.001.
- Uthappa DM, et al. Interfacility transfer outcomes among children with complex chronic conditions: associations between patient-level and hospital-level factors and transfer outcomes. Hosp Pediatr. 2024;14(2):e91-e97. https://doi.org/10.1542/hpeds.2023-007425.
- Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proc (Bayl Univ Med Cent). 2001;14(4):339-46. https://doi.org/10.1080/08998280.2001.11927785.
- Vazquez JR, et al. 5 Best practices and resources for interhospital transfers. The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/38755/practice-management/5-best-practices-and-resources-for-interhospital-transfers/. Published April 1, 2025. Accessed September 16, 2026.