Home health and palliative care for ALW residents

You keep clinical control of your service. A resident enrolled in California's Assisted Living Waiver (ALW) has a Care Coordination Agency (CCA) that keeps the ALW care plan (the Individualized Service Plan, or ISP). The facility keeps the duties its license covers, including some personal care under that plan. Tell the CCA before the first visit.

Coordinate care with the ALW team

Important: This general guide does not establish whether home health or palliative care is clinically appropriate, covered or coordinated correctly for a particular person; qualified clinical, payer and ALW review is still needed for the individual situation. You keep clinical control of your service. The CCA keeps the ISP. The facility keeps its licensed residential duties. Beta is a CCA, not the treating clinician, the facility licensee or the payer. In an emergency, call 911.

Keep the roles separate

What changes is the resident's enrollment in ALW. An enrolled resident has a CCA and an ISP.

ALW: the CCA does the ALW assessment, arranges the waiver services in the ISP and visits monthly.
Home health: you provide the ordered skilled services under your orders and your payer's rules.
Palliative care: you provide symptom-focused and supportive care under the resident's clinical and payer model.
Facility: a licensed RCFE helps residents get home health care, follows your service plan for its part and keeps observing the resident between visits (CDSS PIN 22-24-ASC). Every facility works within its license.

Before the first visit

Confirm:

the order, the payer and any authorization
the service goal and the visit frequency
the clinician, CCA and facility contacts
the resident's authorization to share information
medication and equipment changes
facility access and how documents are exchanged
who to call when something changes

Common coordination areas

Area	What to clarify
Skilled nursing	Which skilled tasks you perform, and what facility staff do between visits
Any service	The task, the responsible provider, the payer, the schedule and the facility's role, written down so nothing is paid for twice
Therapy	How recommendations fit facility staff, equipment and the ISP
Wound care	Supplies, treatment orders, the facility's observation role and payer responsibility
Medication changes	That current orders reach the facility and the CCA, and who monitors the response
Equipment	Ordering provider, payer, delivery, training and the facility's ability to support safe use
Change in function	A change in function can affect the ALW assessment, the tier, the ISP and facility fit. Tell the CCA as well as the health plan.

The CCA uses the current DHCS forms for a reassessment, a tier change or an incident report.

Palliative care referral questions

Settle these before the first visit:

which needs the service addresses
who remains the treating clinician
which plan or model the service runs through
what the facility and the CCA should report
whether advance care planning is included
the after-hours process

After a hospitalization

Before services resume, confirm:

new orders and medication reconciliation
new equipment and any change in function
payer authorization
the facility's ability to support the plan
whether the CCA needs to reassess

Send the coordination request before the first visit. If the first visit is less than one business day away, call instead. The request takes your professional details and a note of up to 300 characters, with no resident names, health details or identifiers. Beta's ALW team names the route for records once you are in touch.

The ALW assessment explains what the nurse looks at. This guide is part of ALW for hospice, home health and palliative care teams.

When a hospice or home-health team shares a patient with ALW, the care coordinator coordinates with whichever agency the person chose. Beta's ALW team does not recommend one. How hospice and ALW work together.