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

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AFL 20-42 From the California Department of Public Health

April 24, 2020

TO: All Facilities

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

All Facilities Letter (AFL) Summary

This AFL provides information on 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 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 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. 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 IV fluids and hi-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 to severe dementia, who are 2-person assist or non-ambulatory, 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 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.

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. The process includes:

  1. The transferring facility calls the All-Access Transfer Center (AATC) to request the transfer of a stable, COVID positive patient to an alternate care site.
  2. AATC will do an initial screening using the admission guidelines and connect with the appropriate alternate care site.
  3. The facility intake coordinator will coordinate confirmation of the transfer including medical records and test results.
  4. The facility intake coordinator will call AATC who will coordinate the physical transfer of the patient. 

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