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

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AFL 20-48.3 From the California Department of Public Health

December 16, 2020

TO: All Facilities

SUBJECT: Transfers to Low Acuity Alternate Care Sites During Coronavirus Disease 2019 (COVID-19) Pandemic (This AFL supersedes AFL 20-48.2)

All Facilities Letter (AFL) Summary

  • This AFL provides information on state-run 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.
  • This AFL also addresses transfers to congregate living health facilities licensed by the California Department of Social Services (CDSS).
  • This guidance has been updated to revise the admission criteria and to provide additional information regarding effectuating a transfer between the alternate care site and health facility.


The COVID-19 virus has infected more than a million people in California, resulting in thousands of hospitalizations and ICU admissions.  One of the challenges of COVID-19 is that many infected individuals are asymptomatic or have mild symptoms and can unknowingly transmit the virus to others. Throughout the pandemic, elderly individuals have been disproportionately impacted, with the highest mortality rates in those over the age of 80. With anticipated surges in cases, strategies are needed to provide care for less sick patients at sites outside acute care hospitals 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 increased 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.

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, provided that the admitting alternate care site has the appropriate level of services and staffing. The patients selected are to be at lower risk for decompensation and semi-ambulatory.

Alternate care sites have all or some of the following:

  1. Staffing that includes a combination of physicians, nurse practitioners, physician assistants, nurses, personal care attendants, respiratory therapists, behavioral health workers, pharmacists, supportive medical care providers, and social workers
  2. Ability to provide limited IV fluids/medications and low-flow oxygen (up to 4 L NC and 6 L NC may be considered at physician discretion).
  3. Nebulizer treatments and suctioning, if the appropriate personal protective equipment (i.e. N95) and setting (single room) are available. 

Basic laboratory testing and x-ray capabilities may also be available on a site-by-site basis.

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 activities of daily living needs, such as individuals who are 1-person assist or require assistance with feeding and toileting. Admission criteria for each alternate care site may also differ based upon patient acuity. For admission information, please contact your Medical Health Operational Area Coordinator (MHOAC).

Transfers to Alternate Care Sites

Alternate care sites cannot offer all 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 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. 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 three 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 transfer center serving their geographical area 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 via the 911 system.

Patients with COVID-19 who are asymptomatic or have mild symptoms 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. 

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