ALW for Hospice and Healthcare Partners

A participant in California's Assisted Living Waiver (ALW) can also receive hospice, home health or palliative care. The waiver doesn't replace any of them, and you keep clinical control of your service. What ALW adds is a Care Coordination Agency (CCA) that owns the service plan and monthly check-ins, and a facility that carries the residential care. The work is deciding which service belongs to which benefit so nothing is duplicated or dropped.

Coordinate Care With the ALW Team

Important: Concurrent services are reviewed case by case. Hospice, home health and ALW do not automatically work together, and no page can settle coverage for an individual patient. 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. Never send medical records or identifiers by ordinary email; the secure coordination form is the channel.

Choose your task

Task	Guide
Coordinate hospice for an ALW participant, patient choice, facility requirements, the hospice benefit, medications and durable medical equipment (DME), and nonduplication (no service billed or delivered twice)	Open the ALW + Hospice Guide
Coordinate home health or palliative care, how skilled services, orders, facility responsibilities and the ALW care plan (the Individualized Service Plan, or ISP) line up	Open the Home Health and Palliative Care Guide
Refer a new patient to ALW through the secure referral form	Refer a patient or client

Start with the role map

Party	Primary role for a shared patient
Participant or representative	Chooses providers and authorizes communication
CCA (Beta)	Coordinates the ALW assessment, the ISP, covered waiver services and monthly monitoring
Facility (RCFE or ARF)	Provides residential care and ALW services within its license and enrollment
Hospice	Provides elected hospice services for the terminal illness under the hospice benefit
Home health	Provides ordered, covered 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

Questions to settle together

Which services are already in the ALW ISP, and which are covered by the healthcare benefit? Could any service, supply, DME or staffing responsibility overlap? What stays the facility's responsibility, and what does the CCA need to reassess? Who tells the participant about changes, what happens after a hospitalization, who covers after hours, and how is patient choice documented?

The coordination request asks for the participant's authorization, each party's contacts, the payer, the current ISP and plan of care, diagnoses, medications, DME and visit schedule.

When to loop in the care coordinator

Hospice election or discharge; home health starting or stopping; new DME; a medication change that affects facility care; a hospitalization; a change in mobility, cognition, symptoms or safety; or a change of facility or decision-maker. See the full change-of-condition triggers.

Your next step

Start the coordination request for a shared patient, or refer someone new. Beta's ALW team can clarify the ISP, check whether a change needs a reassessment, coordinate with the facility, and help avoid gaps or duplication.

Coordinate Care With the ALW Team

Refer a patient or client