Your Hospital Stay      Patient Care Coordination

Patient Care Coordination

The Patient Care Coordination Department (PCC) works directly with Antelope Valley Hospital patients to ensure a smooth transition back to the patient’s home.

This process includes:

  • Hospital Discharge Planning
  • Post-Hospital Care Planning
  • Counselors/Social Worker support services (as needed)

PCC Case Managers work with patients to develop a specialized care plan based on individual needs and conditions. This process begins when the patient is admitted to the hospital, and includes interviews with the patient, family members of the patient, and physician to accurately identify needs and evaluate options for post‑hospital care.

Discharge Planning
Patients typically require additional recovery time after they are discharged from the hospital. As a result, the patient discharge process can involve a great deal of information and detailed instructions. PCC Case Managers help patients through this process while determining what patients need for a successful transfer from one level of care to another.

Post‑Hospital Care Planning
Post‑hospital care may include home medical equipment, acute rehabilitation, skilled nursing care, custodial care, board and care, home health care and hospice. PCC Case Managers help to coordinate post‑hospital care while liaising with patient physicians and insurance companies. PCC Case Managers also assist by helping to maximize insurance benefits coverage, and advising if any services or portion of post‑hospital care will not be covered by insurance.

Counselors/Social Workers
PCC social workers are available to provide assistance to patients and family members coping with social, emotional and environmental problems associated with illness or disability. 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
  • Working with victims of child and adult abuse

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.

 Acute Hospital Care

During this phase of care, physicians determine a patient’s 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 a higher level of care following a hospital stay may be referred to an Acute Rehabilitative Unit or a Skilled 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. PCC case workers can help locate the closest SNF capable of meeting the requirements needed for care.

 Acute Rehabilitation Unit (ARU)

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 rehabilitation unit. There are various guidelines and requirements in order to meet the admission criteria. These include the patient being able to tolerate three hours of therapeutic services per day, at least five days per week, and the patient must require 24‑hour rehabilitation nursing care.

 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 no sub‑acute facilities in the Antelope Valley area.

 Long Term Acute Care (LTAC)

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 provide continued acute care until transition to a lower level of care or home is possible. 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.


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 of care focuses on comfort, pain control and quality of care. Hospice care is a service which can 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 consultation with the company of patient’s choice.


Patient Care Coordination Department