Harbor:ED follow-up options

Patients who CANNOT follow up at Harbor

• There is an orange OOP icon (“out of plan/out of county”). Think “oops!, my patient cannot follow up here at Harbor.” Only patients with the green DHS icon are eligible for follow up within the DHS system.
• MyHealthWayLA has outside resources for PMD follow up.
  • Refer to PMD or HMO plan
  • If patient wants to switch to Harbor network, they must call their insurance company to change it.
  • Some instances, patient's PMD/insurance can give pre-authorization for care at Harbor.

Patients who CAN follow up at Harbor

Primary care or non-urgent (>2 weeks) specialty care referrals

• Non Urgent PMD referrals: use CCC for all patients with >=1 chronic ambulatory-care sensitive condition, i.e. COPD, asthma, htn, HL, DM, CAD, CHF, seizure disorder. Those that don't quality due to not having an ambulatory care sensitive condition, please give CHC list (each clerk's desk has them). See the separate CCC section for details. If your patient is homeless, can consider scheduling into Lomita FM so patient can leave with appointment in hand.

• DHS empaneled patients requiring non-urgent specialty care–→ Can refer via CCC, or have them ask their PMD to place an E-Consult. If you’re referring for hernia repair, please document the hernia size and location, and pt’s BMI and comorbidities. If you’re referring for elective cholecystectomy, please document the pt’s BMI and comorbidities.

Urgent Specialty Care referrals (less than 2 weeks):

• DHS empaneled/LA County uninsured: call specialty service for approval and have clerk book in Orchid
• Limited Lomita/Family med and expedited workup clinic spots
• Out of county uninsured: have the patient call 2-1-1 from anywhere in California for a call center/clearinghouse for health services.
• Insured patients: Refer to their own health plan

Specialty Clinics We Can Book Into After Consultation

Get name of approving physician

• Ortho
• Derm
• ENT
  • Discharge the patient from the ED to ophtho, ENT clinic, Ortho Cast Room, unless you feel they have ongoing medical issues that require them coming back to ED
  • If they require admission, can be admitted from there or sent back to ED
• GYN UC (often all booked so have to call)
• Trauma/Acute Care Surgery
• Cardiology
• Urology
• Ophtho

Other Clinics We Can Book into

• Expedited Work Up (see separate section on criteria)
• Family Medicine (reserve for patient's without reliable phone number or address)
• 72 HRS STRESS TEST
• Anticoagulation clinic (write ok to overbook per Dr. French)
• Sport Medicine
• NEVER REFER TO PAIN CLINIC!

Scheduling Outpt Studies

• Stress Testing
  • Order in Orchid "Treadmill Stress Test", clerk will schedule - check with them to see if we have slots open

• US or MRI
  • In general: DON’T DO IT!
  • Try and have the service requesting the study order it

• Outpt Labs
  • Okay in certain circumstances
  • ONLY if patient will have a follow-up appointment in one of our clinics within 1-2 days of the lab draw!

Continuity Care Clinic (CCC)

Follow up in CCC

• Any questions, call CCC ext 8117, Monday - Friday 8AM-4:30PM
• Step 1: The Continuity Care Clinic (CCC) is for patients WITHOUT any resources
  • To check this:

1. Check the empaneled provider section in the banner bar.
2. Check to see if this patient has previously been seen in primary care or family medicine
3. OOP icon or MHLA icon (MyHealthLA)
4. DHS MediCal patients, have assigned PMD but patient may not know, need to call insurance.

• If yes to any of the above, patient cannot go to CCC. They have to contact their clinic/provider and arrange follow up.
• If they want to switch to Harbor UCLA, they can call their own insurance plan, or go to Member Services 1B1 for assistance, ext 5350. For MHLA patients, they can also contact MHLA directly and request the change
• If they are Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.
• The only exception to this is for lab / symptom telephone follow up.

• Step 2: CCC is only for patient's dispositioned HOME.
  • If the patient was dispositioned to Obs/CORE/Psych ED/Admitted, they cannot go to CCC.
  • Don’t place the ‘ED Post Visit Plan’ form for CCC referral until you’ve decided the patient’s final disposition. Otherwise, if you place it too early, you have to cancel or ‘place in error’ the referral form.

• Step 3: CCC/PVCC Functions:
  • CCC hours: Monday - Friday 8AM-4:30PM
  • No abnormal lab result review after hours or on weekends
  • If results addressed by ordering provider or ED, please document in ORCHID what was done.
  • Lab / Symptom / Wound follow-up:
    • Be specific re: f/u time frame when filling out the PVCC form or clinical judgment will be used
  • Referrals though e-consult: only non-urgent, not time-sensitive >2wks f/u
    • CCC review/submission: 24-72hrs
    • Specialist review: 72-96hrs, f/u time frame determined by specialist
    • Appointment Service Center (ASC) contacts patient to schedule the appointment. This is the rate limiting step.
      • To see if the e-consult was approved, you can check 'consultation notes.' If you find that the e-consult was approved, feel free to give the patient their e-consult ID number and the phone number to ASC to schedule their appointment. (855-521-1718).
    • If request for specialty visit <2wks, do not use CCC. Instead, call specialty consultant to schedule appt prior to d/c
    • ED can book directly into some clinics, such as 72 hour exercise treadmill tests, GYN UCC, Sports Med, Expedited Work Up Clinic, etc.
    • CCC does not have access to schedule 72 hour exercise treadmill tests or Sports Med.
    • To facilitate e-consult, if outside records available, ask ED clerk to copy and upload to ORCHID
  • Bridge to getting a PMD if patient has Ambulatory Care Sensitive Condition
    • ACSC (Ambulatory Care Sensitive Conditions):
      • Chronic conditions which appropriate outpt care prevents inpt admission and/or complications.
      • Asthma, CHF, Cancer, CVA, ESRD, CF, DM, HIV/AIDS, IBD, Heart Dz, HL, Neuromuscular dz, Psych d/o, CKD, RA, Sz d/o, Substance abuse d/o, Specified debilitating conditions
      • CCC will work to transition to primary care via NERF submission

• Step 4: fill out ‘ED Post Visit Plan’ in the Depart Process. Select ‘PVCC/CCC – Har’ and fill out the form to put patient on their tracking list.
  • Permission for proxy to assist: Occasionally CCC will need to discuss prior certain health information with a proxy, family/friend of patient, if a patient is disabled with physical, psychological, or cognitive impairment. If you write in your PVCC referral: “{Patient} gives permission for {person's name and relationship} to discuss post ED visit plan of care” then CCC is able to use this as verbal consent for further care coordination.
  • Forgot to do the form, patient off the tracking board. If the patient is already removed from the tracking list, and you want them on the follow up track, you have to go through a couple extra steps to put them on the follow up track. Time limit for delayed submission is 7 days.

1. 1. Highlight your patient on the “HAR Look Up” track
   2. Click ‘Modify Event’ on the toolbar.
   3. Then, manually request the BOTH:
   4. ‘Post Visit PVCC’ for adult patients or ‘Post Visit Peds’ for peds patients,
   5. AND ALSO manually request ‘Post Visit Follow Up’ event to put the patient on the follow up track.

• • If you placed the form by accident, cancel the PVCC form or place ‘in error’ notification. Example, if patient doesn’t get discharged from ED, need to cancel PVCC form if placed earlier.

• Step 5: Finish your ED Provider Note. CCC can’t do anything until you’ve finished your note!
  • I know we all get tired of writing notes at the end of our shift, but we MUST complete our ED Provider Note in a timely fashion, as the CCC can’t coordinate any care unless you’ve finished your note.

Please note:

• CCC generally communicates with us through Message Center if there are any issues.
• Be very careful about your messaging to the patient. They are going to receive a phone call in a few business days. Do not write that they will be contacted or seen within 1-2 days, as CCC needs a little more flexibility than that. CCC is diligent and thorough, your patients will not fall through the cracks. Some patients become angry when the CCC ends up just being a phone call symptom check vs face to face. If you think the patient really needs a face to face, tell them to go to Urgent Care.
• Just like when we filled out the MLK referral form, patients who are being referred for elective cholecystectomy or hernia repair need a BMI in the chart. This determines which service will perform the surgery. You can ask and manually put in the weight. Then CCC staff can just put in the eConsult without having to bring the patient back for an in-person appointment and having all the relevant information easily at hand in the chart.
• Please don't use CCC to obtain stress testing. Keep in mind that the CCC needs at least 2 business days to complete an action. If you want a stress test, please order it and have the clerk book an appointment.

A. Wu, Dir AAED Dec 6, 2016

See Also

• Harbor:Main
• Harbor:Coumadin clinic
• Harbor:Expedited workup clinic

Authors

Ross Donaldson