A long-term acute care hospital transfer moves a patient to another hospital for an extended course of hospital care. Medicare generally uses the term long-term care hospital, or LTCH. The word “long-term” should not be taken to mean a nursing home or permanent residential placement.
Medicare describes LTCHs as caring for people who commonly have more than one serious medical condition. Services may include respiratory therapy and other treatment, and a person may need another care setting after the hospital stay. The transfer conversation should explain the purpose of this stage of care.
Interpret the length-of-stay definition correctly
CMS identifies an average inpatient length of stay greater than twenty-five days in the statutory definition used for LTCH classification. This is a hospital-level average. It is not a requirement that every patient remain for twenty-five days, and it does not establish an individual's expected discharge date.
Ask the responsible team to explain the clinical reason for the proposed setting and the goals that will guide review. Do not use a facility classification number as a substitute for an individual plan.
Match the referral to the receiving hospital
A proposed transfer review separates three questions: what care the patient needs, whether the receiving hospital can provide it and what coverage arrangements apply. Confirm those answers through the appropriate clinical, admissions and coverage teams.
Describe the requested services specifically. A label such as “complex patient” does not identify the support, equipment or expertise the receiving hospital needs to evaluate.
For example, in a fictional referral, the sending team has identified a continuing hospital need but a particular equipment arrangement remains unconfirmed. The referral record should preserve that unresolved question. An available bed is not, by itself, the answer.
Prepare a precise nursing handoff
Use the organization's transfer process to communicate the current plan, recent changes, authorized instructions, communication needs and outstanding tasks. Identify where the supporting records can be found and whom the receiving team can contact.
Distinguish a current order from a historical treatment, and a completed action from a recommendation awaiting a decision. Medication reconciliation and the handoff of outstanding results should have named owners within the transfer process.
Check that the receiving team has the information needed for arrival. If the patient's condition or plan changes before departure, communicate the change through the appropriate clinical route and have the transfer arrangements reviewed.
Keep the patient oriented to the whole journey
Explain the destination, the reason for the move and who will be responsible for care there. Invite questions about visiting, communication, belongings and how future progress discussions will occur.
Avoid promising that the next destination will be home. Medicare notes that people may receive skilled nursing or other long-term care after LTCH discharge.
A useful transition record leaves the patient and receiving team with the same account of what is known, what remains undecided and when the plan will be reviewed.
Compare the receiving service with the patient’s actual needs: skilled nursing facility transitions and inpatient rehabilitation involve different care settings. Complete medication reconciliation with the receiving team rather than assuming that a longer hospital stay makes the transfer orders clear.
Sources
- Long-Term Care Hospital Services (accessed 2026-09-17) — Medicare.gov.
- Long-Term Care Hospital Prospective Payment System (accessed 2026-09-17) — CMS.