Safe Hospital Transfers and Returns for Residents of Long-Term Care Facilities in Viet Nam: Building a Two-Way Care Pathway
INTEGRATED CARE & CARE TRANSITIONSLONG-TERM CARE QUALITY
INTEGRATED CARE & CARE TRANSITIONS · LONG-TERM CARE QUALITY
Last reviewed: October 2026
An older woman living in a residential long-term care facility in Viet Nam is transferred to hospital after developing an acute illness. The hospital team assesses and treats her. Several days later, her condition has improved sufficiently for inpatient treatment to end, and her daughter is informed that discharge is being arranged.
The family expects her to return to the same facility. However, her care needs have changed. She now requires more assistance with walking and personal activities, her medications have been adjusted, and further clinical follow-up is necessary. The residential facility has not yet received the discharge information or confirmed whether its staff can provide the additional support.
The hospital considers her medically ready for discharge. The facility is uncertain whether it can safely receive her. Meanwhile, the older woman and her family are left wondering what will happen next.
A different problem can arise when a resident is first transferred to hospital. The emergency department may receive limited information about the person's usual cognitive abilities, mobility, medications or daily care requirements. Without that background, clinicians may struggle to distinguish a longstanding limitation from a recent change or understand what the person was able to do before becoming unwell.
These situations expose an important vulnerability in the relationship between hospitals and residential long-term care facilities. Moving a person between organizations also requires the transfer of information, coordination of professional responsibilities and decisions about what care can safely continue in the receiving setting.
The central question is: How can hospitals and residential long-term care providers in Viet Nam establish safe, coordinated two-way transfer pathways that maintain clinical continuity and confirm that the receiving service can meet each older person's needs?
The answer involves more than preparing a referral letter or discharge summary. Both organizations need reliable communication, clearly defined responsibilities and a way to confirm that essential care arrangements will be available at the next destination.
For someone already living in residential long-term care, returning after hospital treatment is not necessarily a continuation of the previous arrangement. The person may have different functional abilities, new treatment requirements or a greater need for professional support. Sometimes these changes are temporary. In other circumstances, they may require lasting adjustments or a different care setting.
This article focuses specifically on the Residential Long-Term Care–Hospital Transfer and Return Pathway for older people who are already residents of long-term care facilities.
It does not revisit the detailed recognition and management of acute deterioration, general hospital-to-home transitions or initial admission procedures for new residential care residents. Its focus is hospital transfer, clinical handover, responsibilities between organizations, readiness for return and review after the person resumes residential care.
For Viet Nam, establishing a reliable pathway across these transitions offers a practical opportunity to strengthen patient safety, continuity and quality accountability between healthcare and long-term care.
Why Two-Way Transfers Require a Coordinated Approach
Hospitals and residential long-term care providers often hold different kinds of information about the same person.
Residential staff may know how the person normally communicates, how much assistance they need with everyday activities, which medicines they take and how they respond to unfamiliar surroundings. This knowledge develops through routine care and can be particularly valuable when someone has cognitive impairment or communication difficulties.
Hospitals have different capabilities and responsibilities. Their teams assess acute illness, conduct diagnostic investigations, provide medical treatment and determine whether hospital-based care remains necessary.
A safe transfer connects these perspectives. When a resident moves to hospital, information about their usual condition helps the receiving team understand the clinical presentation. When the person leaves hospital, information about treatment and changes in care needs helps the residential provider prepare for continuing support.
Neither organization can assume that the other already has everything it needs.
International guidance recognizes these transitions as coordinated processes rather than isolated administrative events.
Australia's Strengthened Aged Care Quality Standards, which took effect in November 2025, include Outcome 7.2 on Transitions within Standard 7, The Residential Community. The requirement is reflected in Section 15-40 of the Aged Care Rules 2025, as amended.
Outcome 7.2 addresses planned and unplanned transitions and requires clear responsibility and accountability across aged care workers, healthcare professionals and organizations. Associated regulatory guidance emphasizes timely information sharing, the involvement of older people in decisions and review of their services when they return.
In England, the National Institute for Health and Care Excellence (NICE) guideline NG27, Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults With Social Care Needs, emphasizes coordinated discharge planning, communication between health and social care providers, and the involvement of individuals receiving care.
NHS England's Providing Proactive Care for People Living in Care Homes – Enhanced Health in Care Homes Framework, Version 4, updated in March 2026, further supports collaboration among care homes, primary care and other healthcare services.
These international frameworks are useful references, but their legal and organizational requirements should not be assumed to apply automatically in Viet Nam.
Their shared message is that safe transitions depend on coordinated decisions, appropriate information exchange and a clear understanding of who is responsible for the next stage of care.
Understanding the Legal and Professional Boundaries in Viet Nam
The transfer of an older person between a residential long-term care facility and a hospital must be considered within the legal framework applicable to each participating organization.
The Law on Medical Examination and Treatment No. 15/2023/QH15, effective principally from January 1, 2024, provides the main framework for medical examination, treatment, patient rights, professional responsibilities and emergency care.
Its applicable provisions should be read alongside subsequent amendments, including those reflected in Consolidated Document No. 26/VBHN-VPQH issued by the Office of the National Assembly on February 26, 2026.
Article 61 addresses emergency care, including emergency care within medical examination and treatment establishments and prehospital emergency services. Other provisions regulate relevant responsibilities concerning healthcare activities, medical records and patient transfers between medical examination and treatment establishments.
An important distinction must nevertheless be maintained.
A resident moving from a long-term care facility to hospital is not necessarily undergoing the same legally regulated transfer process as a patient moving between two licensed medical examination and treatment establishments.
A residential care provider does not automatically acquire the professional authority of a hospital or clinic because it employs nurses, supports medication routines or regularly communicates with physicians.
The residential facility must operate within its authorized service scope. Medical examination, diagnosis and treatment must be carried out by appropriately authorized healthcare practitioners and organizations.
The Law on the Elderly No. 39/2009/QH12 and Decree No. 06/2011/NĐ-CP provide further legal foundations for older-person care services and relevant care agreements.
Social assistance establishments are also subject to applicable organizational and operational requirements, including relevant provisions associated with Decree No. 103/2017/NĐ-CP and subsequent legal developments.
A more recent development is Decree No. 335/2026/NĐ-CP on social assistance policies, effective October 5, 2026.
Article 25 addresses records maintained for individuals receiving care at social assistance establishments, including health records, social assistance plans and other relevant documentation.
Article 26 identifies circumstances in which care at such establishments may end, including when an establishment no longer has the capability to provide necessary services.
These provisions are relevant when a resident's needs change substantially after hospitalization. However, they apply within the decree's specific social assistance framework and should not be interpreted as giving every residential provider an automatic right to refuse a returning resident or terminate an existing care arrangement.
The applicable legal consequences depend on the type of establishment, the resident's status, relevant service agreements and statutory procedures.
As of October 2026, the legal instruments reviewed do not establish a single nationally standardized two-way hospital–residential care transfer protocol that applies identically to every residential provider in Viet Nam.
Hospitals and residential facilities should therefore clarify their respective legal and professional responsibilities before introducing collaborative transfer procedures.
A shared transfer pathway can improve coordination, but it cannot expand either organization's authority beyond what the law permits.
Preparing for Hospital Transfer Before It Is Needed
A safe transfer begins with arrangements established before a resident requires hospital assessment.
The residential provider should know how appropriate healthcare assistance can be obtained, how transportation will be arranged and what information needs to accompany the person.
An accurate resident information record is an important starting point. It should contain relevant health conditions, current medicines, known allergies, usual functional abilities, communication requirements and appropriate contact details. Information should be kept sufficiently current to support an unexpected hospital visit.
The facility should identify who coordinates transfers and communicates with the receiving service. Depending on the organization, this responsibility may be assigned to a nursing professional, care coordinator or designated manager acting within their lawful role and competencies.
Coordinating a transfer does not independently confer clinical authority. A person responsible for organizing transport or preparing documents is not necessarily authorized to diagnose illness or change treatment.
For planned transfers, the facility may have time to confirm the destination, relevant documentation and practical arrangements.
Urgent transfers require a process that can operate promptly without unnecessary administrative steps.
When emergency medical assistance is necessary, appropriate emergency services should be activated without delay. Viet Nam's medical emergency number is 115, although prehospital emergency response capacity and transportation availability vary between localities.
Residential providers should understand the practical arrangements in their area rather than assume that an ambulance or professional assistance will always be immediately available.
Advance preparation should reduce uncertainty and support timely access to necessary hospital care, not create additional barriers.
What the Residential Facility Should Communicate to Hospital
The first important handover occurs when the resident leaves the long-term care facility.
A hospital team needs more than the person's name, age and reason for transfer. It needs enough information to understand the patient's usual condition, relevant history and support requirements.
The sending facility should communicate why hospital assessment was requested, the important changes observed and any relevant professional assessments or interventions already undertaken.
Medication information deserves particular attention. Where available, the record should identify regular medicines, medicines taken when required, relevant administration information and known allergies.
The resident's usual functional and cognitive abilities may be equally important.
An older person who normally communicates clearly but is now unusually confused may require a different clinical assessment from someone with longstanding communication difficulties. Similarly, knowing that a person normally walks with a mobility aid or requires assistance with transfers helps the hospital understand their baseline functioning.
Relevant swallowing, nutritional, sensory or communication requirements should also be shared when they may affect hospital assessment or treatment.
Where appropriate and legally valid, information about the resident's treatment preferences, goals of care and relevant decision-making arrangements should be communicated.
Foreign models of advance directives or substitute decision-making should not be assumed to have identical legal effects in Viet Nam. The receiving healthcare team must consider the applicable legal requirements.
An identifiable contact person is another essential element.
Hospital clinicians may need clarification about the resident's usual cognition, medication history or circumstances preceding transfer. Even a detailed document can be inadequate when nobody is available to explain important uncertainties.
For complex cases, direct communication between the sending and receiving teams may be necessary to supplement written records.
The purpose is not to reproduce the resident's entire long-term care file. It is to provide the information needed for safe hospital assessment and appropriate clinical decisions.
Clarifying Responsibilities During the Transfer
A hospital transfer involves several organizations or individuals whose responsibilities are related but not identical.
The residential facility remains responsible for the services and activities it undertakes within its lawful scope. These may include preparing information, coordinating transportation and communicating with the hospital and appropriate family members.
The hospital is responsible for the clinical assessment, treatment and other professional activities it provides within its authority.
Where a separate transportation service is involved, its responsibilities depend on the nature of that service and applicable legal and professional requirements.
These boundaries should be understood before transfers occur.
A residential provider should not assume that sending someone to hospital ends every responsibility associated with the existing care arrangement. The hospital may still require information about the person's usual condition, and the facility may need to participate in planning their return.
Equally, the hospital should not assume that the residential provider can deliver every form of continuing treatment or assistance recommended after discharge.
For planned transfers, advance communication about the receiving destination can reduce uncertainty. For emergencies, the absence of a prior agreement with a particular hospital should not delay necessary medical assessment or treatment.
A useful operational principle is closed-loop communication: important information reaches an identifiable recipient, with confirmation or clarification when necessary for safe decisions.
This is particularly valuable when several organizations are involved or when the transition depends on a specific action being completed.
The aim is not to introduce more paperwork. It is to ensure that important information has been received and that the people responsible for acting on it understand what is required.
Hospital Assessment May Lead to Different Next Steps
Not every resident transferred to hospital will need inpatient admission.
Some people may receive assessment and treatment in an emergency department and return to their residential facility on the same day. Others may require several days or longer in hospital.
Both situations require appropriate communication, but the time available for planning differs.
When a resident is discharged directly from an emergency department, the facility needs to understand the findings, treatment provided and any immediate changes to continuing care.
The person may have new medication instructions, follow-up appointments or greater assistance needs. A same-day return should not be considered automatically safe simply because inpatient admission was unnecessary.
The receiving provider must understand the relevant discharge instructions and determine whether the required support is available.
When inpatient admission occurs, there is generally more opportunity for coordinated planning.
The hospital should recognize that the person ordinarily lives in residential long-term care and that returning may require confirmation of the facility's ability to meet current needs.
The residential provider should remain accessible for appropriate communication and share relevant information about the resident's usual functioning when requested through lawful channels.
Where significant changes in care requirements become apparent during hospitalization, discussions should begin before the final discharge day.
Early communication may allow necessary equipment, staffing, healthcare follow-up or alternative care arrangements to be considered before the person is ready to leave hospital.
Clinical Discharge Readiness Is Not Residential Return Readiness
This is the central distinction in a safe two-way transfer pathway.
A hospital may determine that a patient no longer requires acute inpatient treatment. That decision concerns the person's medical condition and need for hospital-based services.
It does not automatically establish that the original residential facility can provide the level of support needed after discharge.
Consider an older resident who previously walked short distances with a mobility aid. After hospitalization, the person may need assistance from two workers for transfers or equipment the facility does not currently have.
Another resident may return with a treatment regimen requiring professional administration or monitoring beyond the residential provider's authorized scope. Someone else may have new swallowing difficulties, reduced functional ability or greater communication and supervision needs.
These changes do not necessarily prevent return to the original facility. They do require confirmation that appropriate support can be provided.
Two decisions must therefore be distinguished.
Clinical discharge readiness concerns whether the person still needs acute inpatient hospital treatment.
Residential return readiness concerns whether the proposed receiving setting can safely provide or arrange the continuing care and assistance required after hospital treatment.
These decisions are related, but they are not interchangeable.
The hospital's clinical judgment does not automatically establish the residential provider's capabilities. Equally, the residential provider's operational preferences should not replace appropriate medical judgment or be used to avoid existing responsibilities.
Where uncertainty arises, the organizations should clarify the person's current needs, identify the resources required and determine whether appropriate arrangements can be established.
Return readiness is a proposed operational safeguard. It should not be presented as a nationally mandated Vietnamese approval procedure or an automatic right for a residential provider to prevent hospital discharge.
Its purpose is to support a safe and appropriate destination while recognizing the legal, clinical and contractual responsibilities of everyone involved.
Confirming Whether the Original Facility Can Resume Care
The residential provider should compare the person's expected post-hospital needs with its current capabilities.
This is not the same as conducting a completely new admission assessment. The person is already a resident, and an existing care relationship may continue.
The relevant question is whether the facility can safely resume the necessary services, including any new or increased assistance.
Changes in mobility may require additional staff time or transfer equipment. Cognitive changes may call for different supervision or communication arrangements. New medicines or follow-up requirements may involve coordination with authorized healthcare professionals.
Some needs may be temporary. A resident recovering from acute illness may require additional assistance for a limited period before regaining previous abilities.
Other changes may be more persistent and require a different level of long-term care.
The facility should consider the resources actually available when the person is expected to return, including staffing across the relevant shifts.
If equipment is needed, the provider should establish whether it can be obtained and used safely.
If professional healthcare is necessary, the relevant service arrangements must be lawful and dependable.
A hospital recommendation identifies a care requirement, but it does not itself authorize a residential provider to perform procedures outside its permitted scope.
Where external healthcare support is required, the arrangements should be confirmed before the return depends on them.
The resident's preferences must also be considered. A change in health condition does not remove the person's right to participate in decisions about continuing care.
If the available information is insufficient, the facility should request clarification from the hospital rather than make assumptions.
The outcome of the readiness assessment should be documented, including whether return is feasible, what preparations are required and who is responsible for completing them.
The Discharge Handover Must Explain What Has Changed
A hospital discharge summary is an essential source of information, but it may not fully explain the practical assistance required after hospitalization.
The residential facility needs to understand what has changed since the resident left.
The hospital's handover should communicate the relevant diagnosis or clinical findings, treatment provided, condition at discharge and continuing medical requirements.
It should identify important medication changes, follow-up arrangements, pending investigations and circumstances requiring further professional assessment.
The responsibility for reviewing and acting on outstanding results should be clear. An investigation ordered during hospitalization should not become overlooked simply because the patient has moved to another setting.
Changes in daily care requirements should also be communicated when known and relevant.
A statement that someone is medically stable may not explain whether they can transfer independently, need assistance with eating or require additional supervision.
If new equipment, increased staff assistance or healthcare support is required, the receiving facility should understand those needs before the person returns.
The handover should distinguish recommendations from arrangements that have actually been confirmed.
Recommending a mobility aid is not the same as establishing that the equipment is available at the residential facility. Likewise, prescribing treatment that requires professional administration does not demonstrate that an authorized professional will be available to provide it.
The discharge information should identify an appropriate contact point for clarification.
For complex transitions, direct communication between the hospital team and a designated residential representative may be necessary.
The objective is to ensure that the receiving organization understands not only what happened in hospital, but what needs to happen next and who is responsible.
Medication Information Requires a Reliable Handover
Medication changes are an important source of risk during transitions between hospitals and long-term care.
A resident may leave the facility taking several regular medicines and return with some discontinued, others adjusted and new treatments prescribed.
The concern is not simply that medicines have changed. It is that the hospital, residential facility, resident and family may hold different versions of the current medication regimen.
The WHO technical report Medication Safety in Transitions of Care, published in 2019, identifies medication discrepancies during admission, transfer and discharge as an important patient safety problem.
It emphasizes structured processes, reliable information, clear professional responsibilities and effective communication.
Before a resident resumes care, the facility should obtain an accurate current medication list and relevant instructions from the hospital.
Staff should compare that information with the existing record and identify discrepancies requiring clarification.
Formal clinical medication reconciliation, prescribing decisions and changes to treatment must be undertaken by appropriately qualified and authorized healthcare professionals.
Residential care staff may identify and communicate discrepancies within their assigned duties, but should not independently resolve complex prescribing questions beyond their professional authority.
The provider must also establish whether prescribed medicines are available and whether the necessary administration arrangements can be delivered safely and lawfully.
This article does not revisit the broader management of polypharmacy, deprescribing or long-term medication optimization.
Its focus is preventing information gaps and unintended treatment discrepancies when responsibility changes between organizations.
Involving the Resident and Family in Return Planning
Hospitalization can be stressful for older people, particularly when they experience cognitive impairment, communication difficulties or changes in functional ability.
The resident should receive appropriate information about the proposed transfer and discharge arrangements and have a meaningful opportunity to participate in decisions as far as possible.
The Law on the Elderly and the Law on Medical Examination and Treatment provide relevant protections concerning individual rights, information and participation in decisions.
Family members may provide valuable information and practical support, but their involvement does not automatically confer unrestricted legal authority to decide on the older person's behalf.
Where a guardian or other legal representative is involved, the applicable legal basis and scope of authority should be verified.
A diagnosis of dementia or the need for assistance with everyday activities does not, by itself, establish that a person lacks legal decision-making capacity.
The resident should understand, as far as possible, where they are expected to go, what support will be available and whether the arrangements differ from those in place before hospitalization.
If the person wishes to return to the original facility, that preference deserves serious consideration.
However, preference alone cannot establish that an organization has the legal authority or practical capability to provide services beyond its scope.
Likewise, a provider's wish to reduce its workload should not override the resident's lawful rights or existing contractual responsibilities.
When the proposed destination is disputed or unsuitable, the participating organizations should explain the reasons and work toward an appropriate arrangement within the applicable legal framework.
Families should not be left to resolve professional disagreements between organizations without adequate information or support.
When Return to the Original Facility Is Not Appropriate
There will be circumstances in which the original residential facility cannot safely meet the person's needs after hospitalization.
The resident may require more intensive assistance, specialized equipment, professional healthcare or supervision beyond the provider's capabilities.
Temporary staffing shortages or disruption of essential services may also affect readiness.
The first question should be whether appropriate, lawful and sustainable adjustments can make return possible.
Additional equipment, revised staffing arrangements or dependable healthcare support may sometimes address the gap. These measures must be feasible and confirmed rather than assumed.
If essential care cannot be provided safely, another arrangement may be necessary.
Depending on the person's needs, this could involve a different residential provider or another appropriate care setting.
However, the decision should not be made solely on the basis of available accommodation, staffing convenience or administrative preference.
Article 26 of Decree No. 335/2026/NĐ-CP recognizes, within its applicable social assistance framework, circumstances in which care may end, including when an establishment can no longer provide necessary services.
This provision does not automatically entitle every residential provider to refuse a resident's return or terminate an existing agreement without following applicable procedures.
Hospitalization alone does not necessarily end the residential care relationship.
The provider must consider the person's legal status, relevant service agreement, applicable requirements and continuing responsibilities.
Where the original facility can no longer provide necessary support, the organizations involved should coordinate an appropriate alternative that protects the resident from avoidable gaps in care.
The resident and relevant parties should receive a clear explanation of the situation, and any new receiving service should obtain the information needed to provide appropriate support.
Neither organization should assume that the other can accept responsibilities beyond its lawful or practical capabilities.
The appropriate response is coordinated planning, not abandonment of the resident or an unsafe transfer.
Confirming the Destination and Practical Arrangements
Before the person leaves hospital, the intended destination and essential continuing care arrangements should be sufficiently clear.
For someone returning to the original facility, the residential provider should receive relevant discharge information and understand the expected care requirements.
The hospital and facility should identify who coordinates the return and whether necessary preparations have been completed.
These may involve medicines, equipment, staff assistance, transportation and scheduled professional healthcare follow-up.
Transportation must reflect the person's condition and support needs.
Some residents may travel with ordinary assistance. Others may require specialized transportation or professional support.
The organizations should not assume that relatives can provide transportation or supervision without establishing what is required and what the family is willing and able to do.
Discharge outside normal working hours deserves particular attention.
A residential facility may have different staffing levels and access to professional services overnight. Arrangements that are feasible during the day may not be available later in the evening.
The pathway should therefore identify how essential discharge information will be received, who can clarify unexpected changes and how necessary support can be confirmed outside routine administrative hours.
No single national discharge confirmation deadline should be assumed to apply to every Vietnamese residential long-term care facility.
Participating organizations should establish realistic arrangements based on the person's needs, local service capabilities and relevant legal obligations.
The important point is that essential requirements are addressed before the return depends on them, rather than assuming that booking transportation or setting a discharge date completes the planning process.
Reviewing Care After the Resident Returns
A transfer does not end when the person arrives at the residential facility.
The receiving team should verify that the resident's actual condition is consistent with the discharge information and that the required assistance can be provided.
Some changes become apparent only when the person resumes daily activities in the residential environment.
Staff should confirm that necessary medicines, equipment, personal assistance and communication arrangements are available.
Where significant discrepancies arise, the facility should seek clarification or appropriate professional review without unnecessary delay.
For example, a resident may return with instructions requiring increased assistance during transfers. If the facility's current equipment or staffing cannot support that requirement, the problem should be addressed promptly rather than postponed until a routine care review.
The facility should also confirm that follow-up appointments, outstanding investigations and continuing healthcare responsibilities are understood.
The existing care plan may need revision to reflect changes in mobility, cognition, treatment requirements or preferences.
Not every hospitalization results in significant changes to long-term care needs. Nevertheless, the facility should verify whether the previous arrangements remain appropriate.
The timing and intensity of review should reflect the resident's condition and the changes identified.
A person with substantial new dependency may require earlier reassessment than someone who returns at their previous level of functioning.
No single post-return review interval should be presented as a universal Vietnamese legal requirement.
The purpose is to determine whether the resumed care arrangement is safe, whether necessary services are available and whether further adjustments are required.
Information Sharing and Data Protection
Two-way transfers depend on relevant information reaching the people who need it.
Hospitals and residential providers may use different record systems, communication methods and professional terminology.
Some facilities maintain electronic care records, while others rely mainly on paper documents and telephone communication. These differences can create gaps, particularly when several healthcare professionals or organizations are involved.
A sophisticated digital platform is not always necessary to begin improving the process.
A standardized minimum information set, clearly identified contacts and dependable communication arrangements can provide a practical foundation.
Digital systems can strengthen continuity when they allow authorized professionals to access accurate, current information securely. However, technology cannot compensate for unclear responsibilities or incomplete records.
Personal information must also be protected.
Viet Nam's Law on Personal Data Protection No. 91/2025/QH15 and Decree No. 356/2025/NĐ-CP, both effective January 1, 2026, establish relevant requirements for personal data processing.
Information sharing should have an appropriate legal basis and safeguards consistent with the sensitivity of the information involved.
The resident's rights and legally valid decision-making arrangements must be respected.
Family members should not automatically receive unrestricted access to medical records simply because they arranged residential care or pay the service fees.
At the same time, privacy safeguards should support lawful clinical communication rather than unnecessarily obstruct essential information exchange for patient safety.
Hospitals and residential providers should establish secure, reliable methods for authorized information sharing instead of relying on informal arrangements that have not been assessed.
Developing a Practical Two-Way Transfer and Return Protocol
The principles described above can be organized into an operational pathway shared between a hospital and one or more residential long-term care providers.
A Residential-to-Hospital Transfer Record can identify the resident, reason for transfer, relevant baseline condition, medication information, assistance requirements and contact details.
A Transfer Coordination and Responsibility Protocol can clarify how the organizations communicate, who coordinates each stage and how incomplete or conflicting information is addressed.
A Hospital Discharge and Clinical Handover Record can communicate the hospital treatment episode, current clinical status, important changes, pending results and continuing care requirements.
A Return-to-Care Readiness Assessment can compare the resident's post-hospital needs with the receiving facility's actual capabilities and identify preparations required before return.
A Post-Return Review Record can establish whether essential assistance is available, whether the resident's condition has been reassessed and whether the care plan requires adjustment.
These documents should function as connected elements of one pathway rather than separate administrative forms.
For example, a change in mobility identified during hospitalization should be communicated in the discharge information, considered during return planning and reflected in the updated residential care arrangements.
Where return is not feasible, the process should document the reason and the coordination required to identify another appropriate destination.
These are proposed operational quality improvement tools. They are not nationally mandated Vietnamese transfer forms or an existing accreditation framework.
Their purpose is to make information, decisions and responsibilities traceable across organizational boundaries without creating unnecessary documentation.
Starting With a Bounded Implementation Pilot in Viet Nam
A realistic starting point would be collaboration between a hospital and one or more appropriately authorized residential long-term care providers.
The participating organizations should first define the types of transfers included and identify their respective legal, professional and contractual responsibilities.
They should then examine how transfers currently occur.
This may reveal incomplete medication records, difficulty contacting the residential facility, missing information about a resident's usual functional abilities or discharge planning that begins before the receiving provider understands the new care requirements.
The organizations can use these findings to agree on a minimum information set, contact arrangements and procedures for resolving uncertainty.
They should also establish how concerns about return readiness will be communicated and reviewed by appropriate decision-makers.
Practical simulation can help test the pathway before routine implementation.
One scenario might involve a resident assessed in an emergency department and returned without inpatient admission.
Another could involve a resident discharged after several days of hospital treatment with substantially increased personal assistance needs.
A third might involve discharge proposed outside routine working hours when the receiving facility cannot immediately obtain necessary equipment or professional support.
The participating teams should examine whether information reaches the right person, whether responsibilities are understood and whether appropriate continuing care can be arranged.
Initial implementation should remain within the actual capabilities of the participating services.
A limited pilot can help determine whether the records are usable, communication is reliable and staff understand their roles.
The pathway should be refined through implementation experience rather than expanded solely because a small number of transfers occurred without major problems.
Measuring the Quality of Two-Way Transfers
The quality of a transfer pathway should not be judged primarily by the speed of hospital discharge or the number of hospital transfers avoided.
A rapid discharge is not necessarily safe. A hospital transfer does not automatically indicate poor residential care.
Evaluation should consider whether essential information was available, whether responsibilities were clear and whether the receiving organization could provide appropriate continuing support.
For transfers from residential care to hospital, relevant measures may include the completeness of baseline information, availability of medication records and reliability of communication.
For transfers back to residential care, evaluation may examine whether discharge information was received, important changes were understood and necessary equipment, assistance and professional healthcare follow-up were arranged.
Return-to-care readiness deserves particular attention.
Cases in which a resident returned before essential services were available should be reviewed, along with situations where timely coordination prevented an unsafe return.
Medication discrepancies, missing equipment, delayed clarification of discharge instructions, overlooked pending results and uncertainty about responsibility can provide useful opportunities for improvement.
Unplanned hospital returns should also be examined in context.
Some may result from new or unavoidable illness. Others may be associated with incomplete information, inadequate preparation or failure to respond to changes in care needs.
Simple readmission counts should not be treated as direct measures of residential provider quality without considering the person's clinical condition and the services involved.
The resident's experience also matters.
Older people should have opportunities to describe whether they understood the transfer, felt involved in decisions and received appropriate assistance after returning.
Families may identify communication gaps or inconsistencies that are not apparent from formal records.
Quality review should focus on whether the participating organizations recognized problems, communicated effectively and made appropriate decisions.
The objective is to strengthen the pathway, not automatically assign blame whenever an older person requires hospital treatment.
Making Two-Way Transfers Part of Integrated Care
Safe transfers between hospitals and residential long-term care facilities depend on collaboration between organizations operating under different professional, financial and regulatory arrangements.
Hospitals provide clinical assessment and treatment within their authorized scope. Residential facilities provide continuing personal, social and other care services according to their legal authority and capabilities.
Neither organization can independently meet every aspect of an older person's needs.
This makes their relationship particularly important whenever a resident moves between settings.
International guidance from Australia, NICE, NHS England and WHO offers useful principles concerning coordination, information sharing, professional accountability and continuity of care.
For Viet Nam, these principles should be adapted to local organizational arrangements rather than copied as though foreign regulatory requirements were automatically part of Vietnamese law.
A practical approach begins with accurate information, designated responsibilities, direct communication when necessary and an explicit assessment of the receiving facility's ability to provide continuing care.
The pathway should work for both planned and unplanned transfers.
It should recognize that some residents can return to their original facility without substantial changes, while others may require additional support or a different arrangement.
A functioning pathway does not require every resident to return to the same setting.
It requires the participating organizations to make appropriate, coordinated decisions about where the person can safely receive the next stage of care.
Safe Return Requires More Than Hospital Discharge
For an older person living in residential long-term care, hospitalization may be temporary, but its effects on everyday support needs can continue after acute treatment ends.
The person may return with improved health, different medications, reduced mobility or new requirements for professional follow-up.
The original residential facility may remain entirely suitable. It may need additional preparation or external support. In some circumstances, another care setting may be necessary.
These possibilities must be assessed rather than assumed.
A safe two-way pathway begins with meaningful information from the residential facility to hospital. It continues through appropriate hospital assessment and treatment, clear discharge communication and confirmation that the receiving destination can meet the person's current needs.
The pathway should not end when transportation is arranged or the resident arrives.
The receiving service needs to confirm that essential care can continue, address important discrepancies and review whether the existing arrangements remain appropriate.
A safe hospital transfer is not complete simply because an older person has left one facility and arrived at another. It requires a receiving service that understands the person's current needs and can provide or arrange the necessary continuing care.
For Viet Nam, developing a structured Residential Long-Term Care–Hospital Transfer and Return Pathway offers a practical opportunity to strengthen collaboration between hospitals and long-term care providers.
The objective is not to prevent hospitalization at any cost or return residents to their previous accommodation as quickly as possible.
It is to ensure that every transfer supports appropriate treatment, informed decisions, clear responsibilities and continuity of care.
As residential long-term care services develop in Viet Nam, the ability to manage these transitions safely and reliably will become an increasingly important part of integrated, age-friendly healthcare quality.
References
National Assembly of Viet Nam. Law on Medical Examination and Treatment No. 15/2023/QH15. Adopted January 9, 2023; principally effective January 1, 2024, as amended. See also Office of the National Assembly, Consolidated Document No. 26/VBHN-VPQH, February 26, 2026.
Government of Viet Nam. Decree No. 96/2023/NĐ-CP Detailing Certain Provisions of the Law on Medical Examination and Treatment. December 30, 2023, as amended.
National Assembly of Viet Nam. Law on the Elderly No. 39/2009/QH12. Adopted November 23, 2009; effective July 1, 2010, as amended. See also Office of the National Assembly, Consolidated Document No. 23/VBHN-VPQH, February 26, 2026.
Government of Viet Nam. Decree No. 06/2011/NĐ-CP Detailing and Guiding the Implementation of Certain Provisions of the Law on the Elderly. January 14, 2011, as applicable and amended.
Government of Viet Nam. Decree No. 103/2017/NĐ-CP on the Establishment, Organization, Operation, Dissolution and Management of Social Assistance Establishments. September 12, 2017, as applicable and amended.
Ministry of Labor, Invalids and Social Affairs of Viet Nam. Circular No. 02/2020/TT-BLĐTBXH Guiding the Management of Beneficiaries of Social Work Services Provided by Social Assistance Establishments. February 14, 2020; effective March 30, 2020.
Government of Viet Nam. Decree No. 335/2026/NĐ-CP on Social Assistance Policies. August 21, 2026; effective October 5, 2026.
National Assembly of Viet Nam. Civil Code No. 91/2015/QH13. Adopted November 24, 2015; effective January 1, 2017, as amended.
National Assembly of Viet Nam. Law on Personal Data Protection No. 91/2025/QH15. Adopted June 26, 2025; effective January 1, 2026.
Government of Viet Nam. Decree No. 356/2025/NĐ-CP Detailing Certain Provisions and Measures for Implementing the Law on Personal Data Protection. December 31, 2025; effective January 1, 2026.
Australian Government. Aged Care Rules 2025, as amended. Section 15-40: Standard 7—The Residential Community; Outcome 7.2—Transitions.
Aged Care Quality and Safety Commission, Australia. Strengthened Aged Care Quality Standards: Standard 7—The Residential Community, Outcome 7.2—Transitions. Australian Government.
National Institute for Health and Care Excellence. Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults With Social Care Needs. NICE Guideline NG27. London: NICE; 2015.
National Institute for Health and Care Excellence. Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults With Social Care Needs. NICE Quality Standard QS136. London: NICE; 2016.
World Health Organization. Medication Safety in Transitions of Care. Geneva: World Health Organization; 2019. WHO Reference Number: WHO/UHC/SDS/2019.9.
NHS England. Providing Proactive Care for People Living in Care Homes – Enhanced Health in Care Homes Framework. Version 4. London: NHS England; March 2026.
World Health Organization. Long-Term Care for Older People: Package for Universal Health Coverage. Geneva: World Health Organization; 2024. ISBN: 9789240086555.