USC IM

Home

• Can go home if independent
• If not independent or needs 24H care, must have someone at home 24/7
• Can get Home Health at Home for IV abx, wound care, PT or OT
• To be eligible for PT/OT, patient will need to have Medicare or a good insurance that has rehab as a benefit; also, PT/OT needs to be recommended by the inpatient Rehab dept

SNF (Skilled Nursing Facility)

• Social Work does all the referrals, and they will not look for a SNF until “Medically stable for transfer to SNF” is written in note under Dispo
• If a patient has Emergency Medi-Cal, they would need to change to Full-scope Medi-Cal via PRUCOL
• SNFs like Medi-Care Part A
• Some commercial insurances have SNF benefits but most don’t so a Letter of Acceptance (LOA) must be done and arranged between UR/insurance/SNF
• Patients must have a skilled need in order to go (IV abx, wound care, rehab)
• If patient does not have a skilled need, he or she can be “custodial care” (i.e., 24H care, needs assistance with ADLs, family cannot take care of pt anymore)
• Can also have SNF w/ hospice
• Meds do not need to be filled at our pharmacy; SNF likes to use their own pharmacy
• IF you go to SNF with hospice, needs POLST form

Other Hospital

• If patient has insurance and has a capitated hospital, then the patient must go to that capitated hospital or the patient may face financial responsibility
• UR nurse arranges all of these transfers, but an MD to MD conversation must happen before the patient gets accepted to the capitated hospital

Rancho Los Amigos Hospital (RLAH)

• Patients can be transferred here for continued medical treatment (i.e., IV abx for patients who are current IVDA and homeless)
• Can transfer here for rehab
• Must be recommended by 2 departments (PT/OT/SW)
• Must be able to do 3 hours of rehab per day to be considered
• Order is placed through ORCHID (Consult to Rancho-Medicine/Rehab)
• Care Coordinator can follow up with UR and RLAH admissions
• RLA Acute Rehab criteria
• RLA Medicine Admission criteria

Recuperative Care/Interim Housing

• Homeless patients can go here temporarily while “recuperating”
• Pts must be independent to be considered there. There is no nurse there. Some places will have a Licensed Vocational Nurse (LVN) during the day but aren’t there to given meds, i.e., patients should be able to administer their own subQ or PO meds
• Can go to recup care is patients need IV abx or wound care, but will need additional Home Health order
  • Bed must be secured first before HH can be arranged because HH needs the housing address and phone number before processing that order
• Order SW for this on ORCHID
• SW will ask MD to fill out Recup form
• Usually takes ~3 days to get accepted depending on the waitlist
• Patient must have at least 30 days of Rx with them

Shelter

• For homeless patients who are independent (i.e., must be able to ambulate at least 200ft or propel wheelchair at least 200ft)
• Place SW order for this
• Patients must leave no later than 2PM if going to a shelter
• All meds, supplies and DC order should be in early in the morning

Housing for Health

• SW always assesses homeless patients for this option
• Patient leaves the hospital without housing but they will need to follow up for updates on the application status of their housing

Board and Care

• Eligible if patient has some ability to complete ADLs
• Can receive IV abx here through HH
• Need SW order for this
• Sometimes patients will need to agree on giving their source of income/money (SSI or general relief funds) to the B&C in order to be accepted

Jail

• Must complete DC summary along with DC order for the Jail liaison to work on transfer back to Jail
• No need to prescribe meds, just give recommendations in DC summary that Jail MD can follow
• Patients get sent back either to General Population or infirmary/CTC
• There is sometimes a waiting list for patients to go back to CTC/infirmary (hospital beds in Jail)

Inpatient Substance Abuse Rehab

• Will need SAC (substance abuse counselor) to see patient and be able to refer the patient
• Order SW; SW will see patient and refer patient to SAC
• If patient stable and with home, patients can also return home and call inpatient facility for an “interview” of acceptance
• Patient must be willing to stay in rehab for 30 days without a break, i.e., no outside appointments can be attended
• SAC will arrange for transportation
• Pt must have 30 days' worth of Rx if transferring from hospital to inpatient rehab facility

Psychiatric Facility

• Can transfer to inpatient Psych facility if Psychiatry says so
• Needs to be Medically stable for transfer to Psych facility
• There’s a MCW (Medical Case Worker) Psych worker that refers patients to different psychiatric facilities
• Sometimes, it’s faster to transfer a patient to other psych facilites if they are still in the ED or OBS

Hospice Securing DME for inpatients: WEEKENDS and AFTER-HOURS

• Wheelchairs, Crutches, Walkers
  • Licensed provider orders the DME in ORCHID order under the Medication tab
  • Order MUST include height and weight of patient
  • Nursing calls 9-2381 to obtain above items
  • Warehouse delivers the items
  • Nursing completes HS-1 Form with the items delivered, including sticking a patient label with Name & MRUN on the HS-1 Form. Nurse assigns the discharging unit as the cost center
• Hospital Beds, 3-in-1 shower chair, bedside commode (Hospital bed may require at least 24 hour notice and cannot be delivered after hours)
  • Nursing calls home health nurse on call (213-919-0509)
  • Licensed provider orders the DME in ORCHID order under Medication tab
  • Licensed provider completes a Certificate of Medical Necessity for the hospital bed (CMN)
  • Licensed provider documents medical necessity in the progress note
  • Home health nurse will call Calox to schedule DME delivery (323-255-5175, Option 1)
  • Calox will deliver DME at the patient’s home

Discharge Lounge

• Patients can be discharged from the discharge lounge if they are waiting for a ride - no need to “hold patient discharge for ride” if they meet criteria below
• DC Lounge Criteria

NERF process

• Follow the process below to link eligible patients to LAC&USC primary care
• NERF Process

HD placement for patients being discharged on a weekend

• Obtaining HD Placement on Weekends