Patient Care Coordination

Almost from the moment you enter the hospital, someone is making plans to ensure that your return home is safe and that you will continue to receive any care you may need. At Antelope Valley Hospital, this transition process is facilitated by experienced professionals in the Patient Care Coordination (PCC) department.

Discharge Planning

Discharge Planning is used to determine what you, as a patient, need for a smooth transfer from one level of care to another. Discharge from the hospital does not necessarily mean that you have fully recovered. It often means that your physician has determined that your condition is stable and no longer requires acute hospital care.

Because your discharge can involve a great deal of information and detailed instructions, PCC works to help you with this process. You will be assigned a case manager who will work with you to develop a specialized care plan based on your needs and condition.

Social Workers

If you or a family member is dealing with social, emotional and environmental problems associated with illness or disability, PCC social workers are available to provide assistance. These knowledgeable and compassionate professionals render services by providing short term counseling, assisting with end of life issues, conducting resource management, assisting with adoptions and surrogacy, assisting parents and families of NICU babies and working with victims of child and adult abuse.

Your PCC Case Manager's Role

Your case manager will lay the groundwork for your discharge when you are admitted to the hospital. He or she will interview you as well as your physician and key family members to accurately identify your needs and evaluate your options for post hospital care.

Through this process, your case manager identifies any additional treatment or care you may need after being discharged, and makes the necessary arrangements. This includes coordination with your physician and your insurance company. Various forms of post-hospital care may include home health, home medical equipment, acute rehabilitation, skilled nursing care, custodial care, board and care, home health care and hospice.

Insurance

Until you actually need your health insurance, you may be unsure of what services it will cover. However, your PCC case manager will coordinate with your insurance company to maximize your benefits, and let you know if any services or portion of your care will not be covered.

Patients and family members are often surprised to learn that their insurance will not pay for many services and items needed at home. Therefore, it makes sense to investigate what post acute care is covered by your insurance as soon as possible, and what your expenses may be. Your case manager can help you get started and carefully review all your options.

Levels of Care

Just as there are many levels of care in Antelope Valley Hospital – from emergency treatment to surgery and intensive care – there are different levels of post-acute care. To ensure a smooth transition out of the hospital and from one level of care to another it helps to understand various types of care. You can ask your case manager to further explain the range of available options and whether your insurance will pay for the services you choose.

Acute Hospital Care

During this phase of care, physicians determine a patient overall treatment plan. This may include acute nursing care, surgery or invasive testing.

Discharge Home

In many cases, patients and their families are safely able to provide ongoing care at home following a hospital stay. Although some follow up care may still be required, it can often be provided in an outpatient setting and may include such things as additional diagnostic testing, physical therapy and dialysis.

Home Health Care

Many medical services that require the skill of a professional can be provided safely at home through home health care. Common home care services include wound care, physical therapy and intravenous (IV) therapy. A nurse or therapist visits the home for about an hour at a time. Home health does not include basic homemaker services.

Non-Skilled or Custodial Care

These options are not usually covered by insurance, although some services are paid for through Medi-Cal or SSI. They include long-term placement in skilled nursing facilities, board and care homes or assisted living facilities.

Skilled Care

Patients who need further care and require more care that could be provided at home may need a Skill Nursing Facility (SNF). This allows the continued provision of skilled nursing care, physical therapy or respiratory therapy in a non-hospital setting. In the Antelope Valley there are four Skilled Nursing Facilities:
Antelope Valley Health Care (661) 948-7501
Antelope Valley Nursing Care (661) 949-5524
Lancaster Health Care (661) 942-8463
Mayflower Gardens Health Care (661) 943-3212

Due to the limited number of facilities in the region, it may be necessary to locate a SNF outside of the Antelope Valley. Your discharge planner will help locate the closest SNF capable of providing the care you need. A listing with all the Skill Nursing Facilities will be provided to you upon request.

Acute Rehab Unit

Patients who have suffered a debilitating injury or illness and who need comprehensive inpatient rehabilitation services to maximize the patient’s potential to restore their functioning independence could be transferred to an acute rehab unit. There are various guidelines and requirements in order to meet the admission criteria. These include patient being able to tolerate 3 hours of therapeutic services per day, at least five days per week and patient needs to require twenty-four hour rehabilitation nursing care. There are no ARUs in the Antelope Valley area, but your case manager will work with your insurance in order to provide you with closest ARU that is contracted with your insurance.

Sub-Acute Care

Patients who require intensive, long-term care management and require more technically complex treatments such as mechanical ventilation, respiratory services, tracheostomy care, total parenteral nutrition (TPN) and rehabilitation may need to be placed in a sub-acute facility until stable to go to the next level of care or home. There are not any sub-acute facilities in the Antelope Valley, therefore, the placement will be out of the area.

LTAC (Long Term Acute Care)

Patients who need to be in an acute care hospital for a long period of time may need to go to a Long Term Acute Care Hospital. These facilities will provide continued acute care until you could transition to a lower level of care or home. While in a LTAC patients are visited daily by a physician and are provided with the clinical services needed. These may include nutritional therapy, telemetry, ventilator support, intravenous therapy, wound care services, rehabilitation services and critical care services. There are several LTAC facilities in the Los Angeles area, however, none are local.

Hospice

Patients who have a confirmed diagnosis of terminal illness and a limited life expectancy could have hospice care as an option. The physician will provide patient and family clinical information about the disease process and could recommend hospice care. Hospice care takes place when curative care is no longer appropriate. This type care focuses on comfort, pain control and quality of care. Hospice care is a service and it could be provided in the comfort of the patient’s home. If this is an option for a patient the Social Worker or Case Manager could provide a listing of all the hospice agencies that service the Antelope Valley area and could arrange a consult with the company of patient’s choice.

Day of Discharge

When your physician decides that you are ready to leave the hospital, a discharge order will be written. You should make transportation arrangements in advance with a family member or friend to help you when it is time to go home.

Although only a physician can authorize a hospital discharge, there are many healthcare professionals involved in the development of a personalized discharge plan. Nurses, physical therapists, respiratory therapists, dieticians and pharmacists are all part of the discharge planning team. PCC nurse case managers, nurse discharge planners and social workers are also involved.

Planning Ahead

Here are some questions you should ask your doctor while planning for your discharge:
Will I need skilled nursing or therapy services?
When will I be able to resume normal activities?
Should I arrange for a ride home or for transportation during my recovery?
Will I need someone to stay with me during my recovery?
Will I need help with bathing, dressing or toileting when I arrive home?
Will I need to go to a rehabilitation center or nursing home? May I choose the center?
Will my insurance pay for my procedure and aftercare needs?
Are there community programs that provide these services or help pay for these services?

For more information about the Patient Care Coordination Department, call (661) 949-5025.