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ED Transfer Process from/to Care Facility (PILOT)


The forms on this page are to be used for the Pen Bay ED Transfer Pilot. Pen Bay's Emergency Department, North East Mobile Health Services and Sterling Ambulance Service are partnering with the homes listed below. Contact information is included for each location.

Pilot Participants
Pen Bay ED
Karen Viet
Roxie Walton 207-596-8319
North East Mobile Health Services
Polly Miller 207-510-0073
Steve Bennett
Sterling Ambulance Service
Jason Wiley
Knox Center    
Carl Chadwick     207-594-6807
Quarry Hill
Stephanie Stimpson    207-230-6208
Windward Gardens    
Tracy Hoppe   207-236-4197 x232


MaineHealth Contact:
Sharon Foerster, 207-661-7595

As you use the forms, feel free to provide feedback to Sharon Foerster in between meetings.

** In the course of your pilot, immediate communication is expected if the pilot process adversely affects patient care in any way. **

Pilot Process Map
This is an overview of the current process, with flagged areas for improvement/change.

To be used by the Care Facility, ED and/or EMS.

Telephone Communication - Pen Bay ED
This form is used to document the nurse-to-nurse call from the care facility calling about sending a resident to the ED.

Transfer to ED Document Checklist
This form is placed on the outside of the manila envelope by the facility.


 Resident Transfer Form
This form is placed inside the manila envelope and includes most important resident information to be communicated to the ED.


SBAR Forms

(1) One-Page SBAR Document


This form is also available on the INTERACT® website. Please note that you must go to the INTERACT® website and agree to use the INTERACT® Licensed Materials as described in the terms of agreement.

Homes might use their own type of form to document the SBAR communication.

ED Discharge to Care Facility
This form was created by the MMC ED and modified for Pen Bay ED use.
Face Sheet
This form will be specific to each SNF/NH but contains standard resident information.
Current MAR
This form will be specific to each SNF/NH documentation.
Advance Directives and Code Status Documentation
Will be what the SNF/NH has on record for the resident. The POLST form will be a state form if the resident has previously filled one out.
Data Tracking Form
This form is to be used by the Pen Bay ED and the Care Facilities in the pilot. Staff from any location (Care Facility ED, EMS and MaineHealth) can use this form to track data and document comments. Please send the form to Sharon Foerster each Friday once the pilot begins.The sub-group will review results periodically.





Phase 1 and Phase 2 Pilots with Maine Medical Center

110 Free Street | Portland, Maine 04101 | (207) 661-7001