Transfers to Low Acuity Alternate Care Sites During Coronavirus Disease 2019 (COVID-19) Pandemic

Please note that this information has been superseded by a more recent item and is only retained here for reference.

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AFL 20-48.1From the California Department of Public Health

May 6, 2020

TO: All Facilities

SUBJECT: Transfers to Low Acuity Alternate Care Sites During Coronavirus Disease 2019 (COVID-19) Pandemic (This AFL supersedes guidance provided in AFL 20-48)

All Facilities Letter (AFL) Summary

  • This AFL provides information on state-run low-acuity alternate care sites and guidance for the transfer of COVID-19 positive patients to alleviate strain on hospitals and skilled nursing facilities (SNFs) and ensure patient safety.
  • The guidance in this AFL has been updated for clarity and to address transfers to congregate living health facilities licensed by the California Department of Social Services (CDSS).

The COVID-19 virus disproportionately impacts the elderly, with mortality increasing with age. Those over the age of 80 with chronic disease have the highest mortality. It also appears to spread easily between people, particularly since younger people often have mild symptoms. Because of the ease of spread, COVID-19 has been widely disseminated, leading to an increase in intensive care unit (ICU) admissions. A strategy is needed to help provide care for less sick patients at alternate care sites to allow hospitals to focus their resources on those with the most acute needs. In addition, given the recent spread of COVID-19 among congregate living sites such as assisted living and SNFs, there is an emerging need for alternate care sites to accommodate COVID-19 positive residents. The decision-making process presumes that all patients admitted to alternate care sites are positive for COVID-19 or persons under investigation for COVID-19.

Definition of Alternate Care Sites
Alternate care sites are low-acuity sites that primarily receive adult patients post-discharge from hospitals and, if needed, from emergency departments for ongoing monitoring. With local and state approval, they may also accept patients directly from the 911 system. In addition, alternate care sites may admit individuals from California Department of Public Health (CDPH) licensed SNFs and CDSS licensed congregate living facilities. The patients selected are to be at lower risk for decompensation and semi-ambulatory.

Alternate care sites have all of the following:

  1. staffing that includes physicians, nurse practitioners, physician assistants, nurses, personal care attendants, respiratory therapists, behavioral health workers, pharmacists, supportive medical care providers, and social workers
  2. basic laboratory testing and x-ray capabilities
  3. ability to provide limited IV fluids/medications and low-flow oxygen
  4. nebulizer treatments and suctioning, if the appropriate personal protective equipment (i.e. N95) and setting (single room) are available. 

The admission criteria for each alternate care site may differ based on the staffing level, equipment available and physical space of the site. Some alternate care sites with sufficient staffing may be able to accept patients with a higher level of ADL needs, including patients who have moderate dementia, who are 2-person assist or require assistance with feeding and toileting.

Transfers to Alternate Care Sites
Alternate care sites cannot offer all of the services a hospital can but can provide care for independent and semi-ambulatory adult patients. Triage centers, SNFs, congregate living facilities and emergency departments may request transfer to an alternate care site for patients who require medical monitoring, as a substitute for low-acuity hospitalization. Hospitals may transfer COVID-19 patients who have stabilized and have lower-acuity needs, but who still require medical monitoring, to make room for those with more acute needs.  SNFs may transfer individuals who meet the admission criteria for alternate care sites. The decision to transfer a patient to an alternate care site will be made by the receiving alternate care site and the SNF, in conjunction with the local public health department, and CDPH. SNFs transferring patients to alternate care sites must hold a transferred patient’s bed for at least 14 days, and, accept the return of a resident from the alternate care site unless CDPH determines otherwise. Facilities must coordinate with their Medical Health Operational Area Coordinator (MHOAC) before initiating a transfer to an alternate care site.

Patients being considered for transfer to alternate care sites should be carefully chosen regardless of site of referral. In both scenarios, all patients should be COVID-19 positive or persons under investigation for COVID-19. The decision-making process may vary depending on the prevalence of COVID-19 in the surrounding community, as well as local hospital capacity. Public health officials may issue state or region-specific guidance that differ from this guidance.

Process for Transfer to Alternate Care Site
The California Emergency Medical Services Authority (CalEMSA) has contracted with four transfer centers across the state to facilitate transfer requests and transportation.

Transfers that occur through this process will be to state-run alternate care sites only. The process includes:

  1. The transferring facility calls the All-Access Transfer Center (AATC: (855) 301-2337) to request the transfer of a stable, COVID-19 positive patient to an alternate care site.
  2. AATC will confirm with the transferring facility that they have contacted their MHOAC or public health department.
  3. AATC will do an initial screening using the admission guidelines and connect with the appropriate state-run alternate care site.
  4. The facility intake coordinator will coordinate confirmation of the transfer including medical records and test results.
  5. The facility intake coordinator will call AATC who will coordinate the physical transfer of the patient. 

Process for Transfer to an alternate care site from Congregate Living Settings:
Any patient who appears acutely ill with concerns for a possible emergency condition should be referred to the hospital by the 911 system.

Patients with mild symptoms who are known to be COVID-19 positive or suspected to have COVID-19, can be referred to the alternate care sites by contacting the AATC. AATC will dispatch an advanced life support (ALS) ambulance to evaluate the patient on-site. 

The ALS ambulance provider will evaluate the patient with the following outcome:

  • If emergency evaluation is felt necessary, the patient will be transferred to the most appropriate emergency department per local Emergency Medical Services (EMS) protocol destination policy.
  • If NO emergency condition is present, the medic will contact the alternate care site physician to review the case and determine if alternate cares site transfer is appropriate.
  • If alternate care site declines the patient, ALS ambulance will transport the patient to the most appropriate hospital per local EMS destination policy.

Alternate Care Site Triage and Assessment of Congregate Living Health Facility Patients:
Intake and triage by physician for residents from congregate living settings may include lab work and x-rays as indicated. After evaluation, the accepting physician will determine if the patient can be admitted to the alternate care site or will need transfer to a higher level of care, using the existing alternate care site process for transfer to higher level of care. 

Transfers from Alternate Care Site to the Hospital
Alternate care sites cannot offer the same breadth of services as a hospital and will not be able to perform the close monitoring needed if a patient’s condition deteriorates. When this occurs, patients may have to be transferred to a hospital, typically via the 911 system, for worsening of their condition. A patient may also be transferred to a hospital if a provider determines they require medical care beyond the level available at the alternate care site for an acute medical issue (e.g., new onset abdominal pain, worsening respiratory status).


Original signed by Heidi W. Steinecker 

Heidi W. Steinecker
Deputy Director