Follow up in CCC

REFER TO ED follow up flow chart

LAB/SYMPTOM FOLLOW-UP: any patient seen in the Adult ED, regardless of insurance or empanelment.

  • Be specific re: f/u time frame when filling out the form or clinical judgment will be used
  • 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 PMD: only DHS patients discharged home, not empaneled on banner bar, not MHLA/OOP.

  • Only for DHS patients without other resources.
  • 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. 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, or go to Member Services 1B1 for assistance, ext 5350. For MHLA patients, they can also contact MHLA directly and request the change if eligible.
    • If they are Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

E-consult for non-urgent specialty referral

  • Only non-urgent/not time-sensitive >2wks f/u. 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.
  • Need BMI and smoking status in chart for patients who are being referred for elective cholecystectomy or hernia* repair.
  • 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 the 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!