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.
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.
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
- 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
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.
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
Home Health Care
Many medical services that require the skill of a professional
can be provided safely at home through
home health care
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
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.
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.
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.