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UNOS News Bureau

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Your transplant program is closing

Published on: Monday, August 31, 2015

New Resource: Guidance for Closing Centers and Collective Patient Transfer

The policy, Allowing Collective Patient and Wait Time Transfers, was implemented Sept. 1, 2015. Related to the implementation of this policy, the Operations and Safety Committee developed a resource that closing programs may find useful. We collected information from other programs that have had to close. Those programs would like to share information with programs in a similar situation about what worked for them.

In its role as the OPTN, UNOS has helped multiple transplant hospitals work through the process of closing a program, either temporarily or permanently. Part of this process involves helping patients find a new transplant program. We have tips and questions and answers for programs that are closing, for those that will be receiving patients, and frequently asked questions by patients.

UNOS/OPTN Policy

You can find all requirements related to closing a transplant program in the OPTN Bylaws Appendix K (Transplant Program Inactivity, Withdrawal, and Termination). You’ll also find the following tables helpful.

Find out who you must notify and what that notification must include.

Notification Details At-a-Glance
Who must be notified? How must they be notified? What is the timeframe for notification? What must the notification include?
OPTN/UNOS Member Quality Department In writing
  • 30 days prior to closing if closing permanently
  • When known if closing temporarily
  1. Reason for closure
  2. Effective date of closure
  3. Sample patient notices
  4. Closure plan with timeline

Patients currently receiving care:

  • Potential candidates
  • Candidates
  • Recipients
  • Living Donors
    • Actual
    • Potential
 In writing by a method that can be tracked and provides proof of receipt At least 30 days prior to closing up to 7 days post closure
  1. Reason for closure
  2. Will not receive organ offers while the program is closed
  3. Options for transfer
  4. Contact name and number for help
  5. Proof of receipt by patient

Time Frames for Transfers

Who must you transfer first?

Closing transplant programs must document:

  • All efforts to transfer candidates to an alternative transplant program
  • If a candidate chooses not to transfer to an alternative transplant program:
    • The reason for not transferring
    • Whether the candidate has been completely informed of the implications of not transferring to an alternative program
  • If a candidate chooses to transfer to an alternative transplant program:
    • The program to which the candidate is transferring
    • The candidate’s progress in transferring to the new program
Time Frames for Transfers
What type of transplant candidate? Transfer time frame Other requirements
Active hospitalized candidates Start within 7 days of closure and complete within 14 days unless:
  • Transfer/discharge would be unsafe
  • Discharge of the candidate is anticipated within this time frame
  • Circumstances outside of the program’s control exist that prevent transfer within 14 days
 Document and submit to UNOS all efforts to transfer hospitalized candidates that are not completed in the required time frame.
Liver: 1A and 1B Within 7 days of closure
Heart: 1A and 1B Within 7 days of closure
Liver: MELD/PELD higher than 25 Within 30 days of closure Transfer according to descending MELD/PELD score.
Multi-visceral Within 30 days of closure
Lung Within 60 days of closure Transfer according to descending Lung Allocation Score
Kidney Within 60 days of closure Transfer candidates with PRA higher than 80% first, then all other active candidates according to waiting time
All inactive candidates Within 12 months of closure

Helpful Tips and Frequently Asked Questions
UNOS and the OPTN Operations and Safety Committee collected information from programs that have had to close. Those programs would like to share information with others about what worked for them.

Tips and FAQs for closing programs

Tips

You are required to notify the OPTN in writing that your program is closing. For additional assistance with the closing process:

  • Contact UNOS Member Quality department at 804-782-4800 as soon as possible or once you have established a closing date. Ask to speak with the Membership Analyst associated with your transplant hospital.
  • Your Membership Analyst will be the designated contact person to guide your program through the necessary steps. Stay in close contact with this individual throughout the closing process.

You are required to notify your patients that the program is closing and provide them with options for transferring to another transplant program.

If you send your membership analyst a draft of your patient notice about your program closure, they can help you ensure it contains all the required elements.

Be sure to notify your patients using a method that can be tracked and that that indicates whether or not they received the notification. Examples include:

  • Commercial overnight delivery service
  • Secure electronic communication
  • Registered or certified mail, return receipt requested

Other transplant professionals who have had to close their program may be willing to share their experiences. For suggestions of someone to talk to, contact your UNOS Regional Administrator (804-782-4800) or consider posting a question on the UNOS Transplant Administrator Listserv.

As soon as you consider closing your program, begin evaluating your waiting list to determine transfer priorities.

  • Once you have developed your patient notification letter, you may want to have it translated in other languages.
  • When you notify the patient, you may want to include the UNOS Patient Notification Letter with your correspondence.
  • Notify the following organizations that your organization is closing:
    • The Centers for Medicaid and Medicare Services
    • Organ Procurement Organizations
    • Histocompatibility Laboratories
    • Insurance Payers
    • Dialysis Centers
    • Referring Physicians
    • State Department of Health
  • You may want include the FAQ for patients in your patient notification letter
  • Your patients should understand that the transplant program they are transferring to:
    • will likely have its own patient evaluation and selection criteria
    • may have different criteria regarding which organ offers they will accept for their patients o is not obligated to accept them as a new patient if they do not meet the new program’s specific selection criteria
  • Although not required, you might want to include the basic selection criteria of any alternative transplant programs you list in your patient notification letter.
  • You may be able to share regional information developed specifically for your area. Here is an example: http://www.nwrenalnetwork.org/T/SelectionCriteria.pdf
  • Document every time you make or attempt to make contact with patients.
  • Helpful hints from staff who have been there
    (Note: these are not recommendations from UNOS; they are lessons from colleagues who have had to shut down their own programs and they would like to share their knowledge):
    • Communicate frequently with the receiving transplant program, so they can help you transfer your patients to their program
    • Form a collaborative plan of action with the receiving program. Give them the name of someone from your program they can contact if they have any questions related to transferred patients.
    • Patients may show different levels of action when it comes to managing their own healthcare. If you contact a patient about transferring to a new program and they don’t respond to your repeated attempts, make sure you document all attempts to contact them in case you later need to remove them from the waiting list.
    • If your patient is covered by commercial payers, talk to a financial coordinator who can help you find transplant programs that are in your patient’s network.
    • Consider hosting a patient town hall to give patients and families an opportunity to meet transplant team members, and hear the steps involved in the waitlist transfer process. Invite any potential local receiving transplant programs so patients can ask them questions.
    • Identify the top five health insurance payers and a primary contact from each to work with during the closure and transfer process. o Hold weekly conference calls with the receiving programs to keep lines of communication open.
    • Think about how you will transfer patient records. Electronic medical records may give you more options.

Closing programs may use a collective transfer process to transfer all of their existing candidates. Appendix K of the OPTN Bylaws lists the specifics required in this process, but the requirements include:

  • A written agreement between the closing program and a receiving program
  • The closing program must complete all required notifications
  • You don’t need to complete individual wait time transfer forms and send them to UNOS, but you must obtain your patient’s consent to transfer
  • The receiving program must submit a plan for evaluating the transferred patients

Frequently Asked Questions

How do we handle patients who are still being evaluated for transplant?

Consistent communication is key when helping these patients transfer to a new program. Tell these patients when your program will close. Give them a list of other transplant programs nearby or in an area they specify. Once you have established where the patient wants to transfer and have proper authorization, you need to send patient records to the new program.

Although not required by policy, it would be helpful if the records should include a copy of the letter you sent to the patient that announced your program’s closing. The records should also include required tests, evaluation documents, and any completed test or study results. Make sure your patient knows that the new program may handle the evaluation and selection process differently. If possible, give your patient a brochure or fact sheet about the new program.

How much detail should we give our patients regarding transfer options?

You should provide as much information as possible. If you are able to get your hands on some written materials from the potential receiving program, you could include those, or even a list of web resources. Include a list of all regional options for transfer and indicate how far these are from your program. Your candidates are not required by policy to transfer to the geographically closest program.

Your patient’s insurance plan, if they have one, will dictate their transfer options since they will be required to use a transplant program in their network. Encourage these patients to work with their case manager. You can give your Medicare and Medicaid patients more general information, including a list of local centers, the SRTR website for data and outcomes, and a list of contact names and numbers at the at the other programs.

Is an individual wait time transfer form required for collective wait time transfers?

No.

What happens to the patients who don’t respond to your attempts to reach them and are not transferred?

Use a communication method that can be tracked and includes proof of receipt. Some options include: commercial overnight delivery service, secure electronic communication, or registered or certified mail, return receipt requested.

Send the patient a certified letter with return receipt requested that indicates you have tried and failed to notify them of your program’s closing and of their future options. Copy the referring MD and the dialysis center, if applicable. Be sure to maintain all documentation for UNOS.

Although you must remove all patients from your waiting list a year after your program closes, you may remove them earlier if you specify a deadline date in your patient communication.

For receiving programs: tips and FAQs

Tips

Receiving a group of potential patients at one time can be overwhelming. Staff from other programs that found themselves in this situation offer the following advice, which you may find helpful. Since evaluating a large group of new patients may take up to several months, some centers found it helpful to hire temporary or permanent staff to assist with the transition.

The closing program may have had different listing or organ acceptance criteria than your program. Even though the closing program is advised to make these differences clear to the patients who are transferring, they may not always do so. Make sure your referred patients are aware of your specific listing and organ acceptance criteria when you first meet with them, so they aren’t caught off guard later.

Lessons learned from other programs that have received patients from closing programs:

  • If possible, consider setting up a clinic where staff from your program and the closing program can evaluate and transition transplant candidates.
  • Collaborate on a plan of action with the closing program.
  • Put together an information packet for your newly referred patients with tips on how to expedite their evaluation process.
  • Track the potential transfer patients together, so you can review progress at regular intervals.
  • Review referrals and identify those who may be able to be fast-tracked for transfer, such as those who have been evaluated recently, or are low risk patients.
  • Communicate with the referring transplant program

Other transplant professionals who have been through a closing situation may be willing to share their experiences. Contact your UNOS Regional Administrator or consider posting a question on the UNOS Transplant Administrator Listserv.

FAQs

How do I manage these patients?

Your discussions with the closing center should include the total number of patients being transferred, including phase of care. Direct your immediate attention to obtaining and training temporary staff to process these patients quickly. Your needs assessments should include administrative staff, financial coordinators, social workers, clinic staff, nursing staff and physicians. You may need to hire temporary mid-level or physician providers to supplement physician staffing. Segregated clinics for transfer patients may be an efficient approach due to similar goals and concerns for the patient population.

If possible, dedicate a receiving nurse coordinator and administrative support staff to manage the transfer patients. Hold weekly meetings with key internal staff (e.g. fiscal, social work, clinic, MDs) to monitor activity, identify issues and develop action plans. In some situations, closing program staff have been hired by one of the receiving centers, which can be helpful.

How have other programs communicated to their existing patients what the impact of these additional transfers might be?

Other programs in this situation found that transparency and honesty are key components to successfully handling this question. They developed talking points on the impact so that all their messages to their existing patients were consistent.

They recommend that you decide whether to send a letter to your existing patients or simply respond to their inquiries. Some of them sent a letter from their medical/surgical directors stating that because of a nearby transplant center closing, there may be one, few, many, or thousands of additional patients coming to the program for care.

Various programs have used the following message points that you might find helpful:

  • Some transferred patients may be transplanted ahead of local patients due to allocation policy.
  • Displaced patients need to be taken care of and it is possible that any patient could end up in a program closure situation.
  • Individual status on the waitlist is determined by their clinical condition (heart, lung, liver, and kidney) and waiting time for other organs.

For patients: FAQs and resources

FAQs

How will I know if my program is closing?

Your transplant program must give you written notice if it is closing or if it will be inactive for 15 days or more. They must notify you using a method that can be tracked and that indicates whether or not you received the notification.

What happens to my care if my program closes?

Talk to your current transplant team. They may continue to manage your care for up to 12 months after they close, while they help you find a new program. Make sure you check with the new hospital to make sure their transplant program is approved. If it’s not an approved program, you won’t receive any organ offers. Find out if they will cover your care during the transition.

How do I transfer to another program?

If possible, talk to your current transplant coordinator. Otherwise, call the transplant program you are considering and schedule an appointment to learn more about their program. If you are comfortable with the transplant program you have picked, find out what you need to do to begin the evaluation process.

With so many candidates, how does my transplant program know who to transfer first?

National rules help transplant programs decide which candidates are most urgent. Your transplant program must make a list of their most urgent candidates, which includes those who are currently hospitalized. This list should include a plan for transferring each candidate. The plan must also include possible programs that could accept the candidate and a timeline for completing the transfer.

Does the new transplant program accept my insurance?

You should check with your insurance provider to make sure the new transplant program accepts your insurance before you begin the evaluation process.

What happens if the new transplant program won’t accept me?

If a transplant program decides you do not meet the standards they have for their transplant candidates, you can be evaluated at another transplant program. Transplant programs will have different standards for transplant candidates. Talk to your transplant coordinator about other transplant programs that you might consider.

Who is responsible for transferring waiting time?

Ask your new transplant program to submit a wait time transfer form to UNOS on your behalf.

I have an approved MELD exception. Will this transfer to my new center?

No, you can’t transfer your approved exception to the new transplant program. If you currently have exception MELD points, or a medical urgency status exception, let your new transplant coordinator know.

Where will I receive my follow-up care?

You will receive your follow-up care at the transplant program where your transplant is performed. However, you may be able to arrange to have your follow-up care at another transplant program, if that program agrees to it. You should inform your current program of your plans to be followed at another program after your transplant.

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