Harbor:ED follow-up options

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FOLLOW-UP

REFER TO


Primary Care Clinics

DHS Patient with Empanelled Provider

  1. Instruct the patient to follow up with their empaneled provider
  2. Use the 'communicate' tool to send a message to the empaneled provider listed in the banner bar
  3. Write a brief message explaining why and when the patient needs follow up
  4. Their empaneled provider can initiate e-consults if applicable
  5. Starting Feb 2018, empaneled providers will automatically be notified of ED visits but you can still message them with any specific concerns

Urgent <2 Week Specialty Follow-up for DHS or MHLA Patients

Write the following items in the follow up field for clerk to book:

  1. Name of approving doctor
  2. Time frame (I.e., 2 days, 1 week, etc.)
  3. Reason for urgent follow up

Discharging Patients Direct to Specialty Clinic

  • In certain situations, patients can (and should) be discharged to a specialty clinic for same/next business day visit (Ophtho, ENT, Cast room, OMFS, etc.). This is considered a continuation of ED care to stabilize their presenting emergent medical condition. Once care is completed in the clinic, the patient should NOT be sent back to the ED.
  • This allows consultants to evaluate and treat patients in their clinic as opposed to coming to the ED
  • The patient CAN BE "OUT OF PLAN" FOR THIS SERVICE as is considered part of ED visit
  • Process/Troubleshooting:
  1. Get agreement from consultant
  2. Must be seen in 24 hours or next business day (if weekend)
  3. ED Care should be complete
  4. Must be during normal clinic operating hours and clinic must be open (Cast room is open until 11 pm 7 days a week)
  5. ED physician should note time and place for patient to follow-up on the ED discharge paperwork, and make sure patient takes paperwork with them to clinic
  6. ED Clerk schedules the visit as appropriate
  7. If any issues, consider attending involvement and/or contact Dr. Roger Lewis via cell.

Dir AED, Chair EM, Dir OPS 9/20/17

Pediatrics CCS Follow up

  • California Children Services (CCS) conditions can be approved for follow up and admission here after discussion with specialist and UR, even if OOP. 
  • Up to age 21 yo
  • New acute illness requiring a subspecialist (new DM, new malignancy/tumor, new seizure d/o, etc.)
  • Call the subspecialist and ask them if patient has a CCS eligible diagnosis, if yes then tell UR and they should be able to be admitted at Harbor or obtain outpatient follow up here at Harbor.

Follow up in CCC

REFER TO

LAB/SYMPTOM FOLLOW-UP

  • DOES NOT INCLUDE Urine cultures or STI follow up anymore (goes to "Lab Follow-Up-HAR"). Otherwise, can be any patient seen in the Adult ED, regardless of insurance or empanelment.
  • Be specific re: f/u time frame when filling out the form
  • CCC reviews requests in a few business days. No abnormal lab result review after hours or on weekends or holidays
  • If you think a patient needs an urgent face to face evaluation, have them go to the Urgent Care if DHS eligible.
  • CCC will only call patient if an abnormal result needs to be addressed. (Example: Urine culture shows antibiotic needs to be switched).
  • For pediatric patients, do not select PVCC/CCC, rather select PED

Bridge to PCP

  • Only DHS patients discharged home, not empaneled on banner bar, not MHLA/OOP.
  • Only for DHS patients without other resources.
    • If unassigned MediCal, patient can go to The Patient Advocate office, Main Hospital PCDC 108 1-B1, Mon and Wed 8a-430p, x64510 to establish empanelment at Harbor
    • If the patient was dispositioned to Obs/CORE/Psych ED/Admitted, we should not place on the CCC track
    • Don’t place the ‘ED Post Visit Plan’ form for CCC referral until you’ve decided the patient’s final disposition. If you place it too early, have to cancel or ‘place in error’ the referral form.
  • Need at least one Ambulatory Care Sensitive Condition (ACSC)
    • Chronic conditions which appropriate outpt care prevents inpt admission and/or complications.
    • Asthma, CHF, Cancer, CVA, ESRD, CF, DM, HIV/AIDS, IBD, Heart Dz, HTN, 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
    • If they want to switch to Harbor UCLA or have problems with their health plan, they can call their own insurance plan. For MHLA patients, they can also contact MHLA directly and request the change if eligible.
      • Patient Relations x66201 can help switch patients to DHS if eligible (2 ED vistis in 6 months, 1 primary care visit in 18 mo, or 2 specialty visits in 12 months)
    • If they are Out of Country/County, and now reside in LA County, they can go to Registration PCDC Rm 108, 1st floor main hospital, ext 64150 to change their address by bringing any mail or DMV record.

E-consult for non-urgent specialty referral

  • DHS patient discharged home, not empaneled, not MHLA
  • Only non-urgent/not time-sensitive. If request for specialty visit <2wks, do not use CCC. Instead, call specialty consultant to schedule appt prior to d/c
    • Appointment Service Center contacts patient to schedule the appointment around 2 weeks just to start arranging follow up.
    • If e-consult submitted already, patient can call ASC themselves to schedule their appointment 855-521-1718.
  • CHOLE patients: need formal RUQ US prior to clinic evaluating patient; please include BMI and smoking status in chart.
  • Hernia patients: need size, description of type, contents, and reducibility as well as BMI & smoking status
  • Ophtho patients: need visual acuity documented
  • If outside records available, ask ED clerk to copy and upload to ORCHID

How to submit CCC referral

  • 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. Make sure there is a correct phone number.
  • Forgot to do the form, patient off the tracking board?
    • Highlight your patient on the “HAR Look Up” track
    • Click ‘Modify Event’ on the toolbar.
    • Then, manually request BOTH:
      • ‘Post Visit PVCC’ for adult patients or ‘Post Visit Peds’ for peds patients,
      • ‘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.
  • Finish your ED Provider Note. CCC can’t do anything until you’ve finished your note!


MAT/BUP/Opiate Withdrawal

  • Please refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to PVCC/CCC – Har for enrollment in Dr. Brown's addiction clinic
    • In the "For referral, specify need" box: "MAT for opiate/alcohol dependency"

Qualifying patients

  • Active withdrawal or post-overdose: start buprenorphine in ED via buprenorphine protocol
  • Not in active withdrawal but with opioid use disorder: rx for home start using home initiation protocol
  • Patients with chronic pain and opioid dependence with PMD at Harbor: message PMD AND Christopher Brown AND Gloria Sanchez to link patient to Harbor SUD clinics
  • For pregnant patients - once the primary complaint is addressed (or if primary complaint is pregnant and opiate use disorder/withdrawal), if patient has confirmed IUP please send to OB triage for initiation of Suboxone during pregnancy

Consult Whole Person Care for ALL patients started on or prescribed buprenorphine in the ED

Narcan Distribution from ED

  • Available for any patients that meet criteria for Narcan distribution and would benefit from distribution
    • In Code White cabinet in purple doc box, next to the adult airway cabinet, requires key from either senior resident phones or either attending phones
    • Please initial to log the distribution on the clipboard attached, no PHI is required
  • All patients distributed Narcan also need it prescribed to the pharmacy for tracking purposes
  • Please document as you otherwise would for prescribing Narcan, with the addition of .ednaloxonegiven in your note, which can soon be replaced by .naloxoneEDdistribution
  • Thank you for helping!

MAT Provider Consultation Line

  • DHS on-call providers available to help initiate MAT for patients with alcohol and/or opioid use disorder
    • (213) 288-9090
    • 8a-12a, 7 days per week
  • Flier: Mat Consult Line.pdf

BUP/MAT Treatment and Discharge Pathway

Patient Discharge Handout

BUP Home Initiation

Patient MAT/Buprenorphine Follow Up Options

Insurance Clinic Hours
DHS Empaneled and DHS Eligible (not Harbor Family Medicine) Primary Care & Diagnostic Center (PCDC) - Basement Clinic C

1000 W. Carson St
Torrance, CA 90502
(424) 306-4546

Schedule as "HAR PC MAT New" or

Walk-In: Monday AM or Thursday AM
For questions, please message Chris O. Brown, MD via ORCHID/Outlook

DHS Empaneled and DHS Eligible Lomita Clinic

1430 W Lomita Blvd, 2nd Fl
Harbor City, CA 90710
(310) 602-2600
(424) 306-4193 - SUD Counselor

Walk-In: Tuesday AM or Friday AM

For questions, please message Gloria Sanchez, MD via ORCHID/Outlook

DHS Empaneled, DHS Eligible, MyHealthLA, Uninsured (No OOP) LAC+USC Urgent Care

2051 Marengo St, 2nd Floor
Los Angeles, CA 90033
(323) 409-1000

Walk-In:

Tuesday-Thursday & Saturday
8am-7pm

All Patients Tarzana Treatment Center

5190 Atlantic Blvd
Long Beach, CA 90805
(818) 654-3933

Walk-In:

24/7

All patients can call the Substance Abuse Service Hotline 24/7 for more help (844) 804-7500

Follow up In Other Clinics

For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center x1220 to take over. Patients can also call 310-222-1200 to schedule appointments (Rather than calling the clinic directly).

Anticoagulation (Coumadin) Clinic

  • Book without consultant approval
  • Book at 7d post initiation of anticoagulation
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

Breast Surgery Clinic

  • needs e-Consult via PCP
  • If patient does not have PCP, consider CCC (if patient qualifies) to start eConsult process
    • If urgent needs follow up <2 weeks for DHS patient, consider consult to breast surgery resident (through Trauma surgery) from the ED
  • See above section on Breast Abscess https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
    • For DHS patients with a breast abscess that is s/p bedside I&D, recurrent breast abscess/mastitis, already diagnosed breast cancer, persistent palpable masses (also need biopsy by Radiology's Breast Diagnostic Center as above)
  • For Breast Mass https://www.wikem.org/wiki/Harbor:Operations_manual#Breast_mass.2Fmalignancy
    • Only directly refer here if the patient has imaging and path results; otherwise, they need referral to the Breast Diagnostic Center first

CARDIOLOGY

  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)
  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up. (Cards will message their Mariedel Morales and Sheila Walters IC, the Cardiology clerks to book).
Stress Testing
  • OOP - refer back to in-network PCP for cardio workup
  • DHS empaneled - message PCP for further cardio workup or schedule for stress test
    • 1 - Ensure patient is ambulatory (walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
    • 2 - Send COVID test via "AMB Pre-surgical/Procedure Coronavirus COVID-19 Screening" order
      • Select "nasopharyngeal" then modify order
        • Change order for future visit to "no"
        • Change collection priority to "STAT"
    • 3 - Place order for "CV Treadmill Stress Test"
      • Reason for procedure "Chest Pain"
      • Special Instructions "Schedule in 3-4 business days"
    • 4 - In DEPART section, click "Schedule Follow-up Appointment" so clerk makes appointment prior to patient DC
      • If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
        • 1 - COVID symptoms
          • If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
          • If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
        • 2 - Cardiac Symptoms
          • The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
            • If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
            • If deemed low-risk, stress testing will be deferred to the PCP for follow up
  • DHS Eligible without assigned PCP
    • 1 - Ensure patient is ambulatory(walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
    • 2 - Send COVID test via "AMB Pre-surgical/Procedure Coronavirus COVID-19 Screening" order
      • Select "nasopharyngeal" then modify order
        • Change order for future visit to "no"
        • Change collection priority to "STAT"
    • 3 - Place order for "CV Treadmill Stress Test"
      • Reason for procedure "Chest Pain"
      • Special Instructions "Schedule in 3-4 business days"
    • 4 - In DEPART section
      • ***CCC for NERF*** (get a PCP assigned)
      • Click "Schedule Follow-up Appointment" so clerk makes appointment prior to patient DC
    • If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
      • 1 - COVID symptoms
        • If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
        • If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
      • 2 - Cardiac Symptoms
        • The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
          • If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
          • If deemed low-risk, stress testing will be deferred to CCC for follow up

Drs. Chappell, Shah, & Pillutla 8/19/2020

DERM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ENT

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Expedited Work-up Clinic (EWC)

  • The Expedited Workup Clinic (EWC) is an option for patients who are stable but require close outpatient follow-up for further diagnostic evaluation (ex. uncharacterized mass, anemia, etc). These are patients that would have been admitted otherwise, but are clinically stable. The EWC is for patients who do not have a primary care provider and must have reliable contact information.
  • Clerk books WITHOUT consultant approval
  • HAR CCC Rm 4, every Monday afternoons.
  • Must have reliable contact info, confirm phone number and address
  • Ideal candidates are those patients that would be admitted in the absence of EWC, and do not have a primary care provider. Patients must have reliable contact information to attend this clinic.
  • If no slots available, send a message to CCC to book the patient.
  • Clinical criteria:
  1. New onset ascites: New diagnosis and first presentation of ascites. Requires paracentesis performed in ED to rule out infection, SAAG >1.1, transaminases < 3x normal, rapid HIV, CBC, lipase, CMP. No referral for therapeutic paracentesis alone, No evidence of pancreatitis or biliary obstruction.
  2. Anemia (Hgb< 8g/dL on initial presentation): Requires CBC, peripheral smear, CMP, rapid HIV, ECG, CXR, type and screen No evidence of pancytopenia, HIV, leukemia, active GI/GU bleeding, or evidence of hemolysis. Patients with suspected gynecologic etiology should be referred to the GYN service. Post transfusion CBC required.
  3. Weight loss, unexplained >10% within 1 month or >15% in 6 months: Requires CBC, CMP, ECG, CXR, rapid HIV. Patients with prior imaging must have actual images or be instructed to retrieve images prior to clinic appointment.
  4. Undiagnosed mass (excluding primary breast, brain, renal, head and neck masses): Requires results or radiographic imaging to confirm presence of mass. Patients with prior imaging must have actual images or be instructed to retrieve imaging prior to clinic appointment. Send CBC, CMP, PT/INR, HIV on all patients.
  5. New onset pleural effusion: Requires thoracentesis, CMP, CBC, serum amylase, LDH, and pleural fluid analysis (predominant lymphocytic effusion or high suspicion for Tuberculosis must be admitted). Chest CT only if immediately clinically indicated (ie. suspicion for pulmonary embolism).
  • Patient is stable (T< 38.3c, HR<100, RR <24, BP >110/50, BP <180/110, pulse ox >92% on room air, oriented x 4)
  • Able to be seen in 2-10 business days without significant risk
  • No ACTIVE co-morbidities (ie infection, CAD, CHF, stroke, metastatic cancer, renal failure, dyspnea).

GYN

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Gyn UCC

  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)

Nephrology Clinic

  • For non-dialysis patients only: Don’t need Nephrology fellow approval per Sharon Adler, MD, Chief, Division of Nephrology and Hypertension, 7/28/17)
    • 3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
    • 2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)

Neurosurgery

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

OB

  • For new pregnancy: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment

ONCOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up.
  • Newly diagnosed, metastatic cancer - discuss with oncology fellow p7862

OPHTHO

  • Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
  • All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ORTHO

PEDIATRICS

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Adolescent Clinic

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Cardiology

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PLASTIC SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PULMONARY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


PROCEDURE CLINIC

  • For patient needing recurrent paracentesis
  • From Dr. Anshu Abhat:
  • only available for patients who are empaneled to Harbor-UCLA Internal Medicine or Geriatrics clinic.
  • If an ED provider thinks a patient could benefit from procedure clinic, they should include this in the ER note/documentation (ideal) or message the empaneled provider. Referrals to procedure clinic should only come from PCP's (not from ER providers).

RHEUM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

UROLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

72 HRS STRESS TEST

Place order in ORCHID for "CV Treadmill Stress Test"

  • If test is abnormal, cardiology follow up automatically generated by HEART station.
  • If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.
  • Outpatient P-MIBI Nuclear stress has to be arranged by CORE

FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS

Per DHS Policy 516.1, Out of County/Country Patients who need an urgent follow-up for an emergency medical condition may be provided such follow-up at Harbor

  1. Emergent Conditions:
    1. Places health in serious jeopardy
    2. Threatens serious impairment to bodily functions
    3. Threatens serious dysfunction to any organ or body part
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. Do not arrange follow-up for NON-EMERGENT/URGENT issues
  • If patient is no longer Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

Dir AED, Dir OPS, DHS Policy 516.1 9/25/17

See Also

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