ALW for hospice, home health and palliative teams

You keep your clinical role. Beta is the Care Coordination Agency (CCA) under California's Assisted Living Waiver (ALW). Beta keeps the participant's ALW care plan and makes the monthly visit. The facility keeps the daily care its license covers. Whether hospice, home health or palliative care runs alongside ALW is reviewed case by case with everyone involved. To coordinate a shared case, call or send the coordination request, with no participant details in it.

Coordinate care with the ALW team

Important: Concurrent services are reviewed case by case. Hospice, home health and ALW do not automatically work together. No page can settle coverage for one participant. Beta's ALW team does not replace the treating clinician, the facility licensee, the hospice medical director, the payer or emergency response. In an emergency, call 911. Do not send medical records or identifiers by ordinary email or through the coordination form. Beta's ALW team names the approved route once you are in touch.

Choose your task

Task	Where to go
Coordinate home health or palliative care for a participant	Home health and palliative care for a resident enrolled in ALW.
Coordinate hospice for a participant	Coordinate care with the ALW team, hospice topic, or call.
Refer someone new to ALW	Refer a patient or client
Ask a general professional question	Call (747) 293-5777

Who does what

Party	Role for a shared participant
The participant or their representative	Chooses the setting, services and providers. Authorizes communication.
CCA (Beta)	Does the ALW assessment and writes the care plan (the Individualized Service Plan, or ISP). Arranges waiver services and visits monthly.
Facility (RCFE or ARF)	Provides residential care and ALW services within its license and enrollment.
Hospice	Provides the elected hospice services for the terminal illness under the hospice benefit.
Home health	Provides the ordered skilled services under its benefit.
Palliative care	Provides symptom and supportive care under its clinical and payer model.
Physician or medical group	Directs medical treatment and writes orders.
Health plan or payer	Applies coverage, authorization and nonduplication rules (no service paid for twice).

Nine questions to settle together

Which services are already in the ALW ISP?
Which services does your benefit or payer cover?
Could any service, supply, equipment or staffing duty overlap?
What stays the facility's responsibility?
What does the CCA need to reassess?
Who tells the participant about changes?
What happens after a hospitalization?
Who covers after hours?
How is the participant's choice documented?

How to reach Beta's ALW team

The coordination request asks for your name, organization, role, phone, work email and county, and the topic. You may add a note of up to 300 characters, with no participant names, health details or identifiers. A coordinator calls you back and names the route for any records.

When to contact the care coordinator

Tell the CCA about:

a hospice election or discharge
home health starting or stopping
new durable medical equipment (DME)
a medication change that affects facility care
a hospitalization
a change in mobility, cognition, symptoms or safety
a change of facility or decision-maker

The Facility Operations Guide lists every change to report.

Send the coordination request for a shared participant, or call.