Home Health and Palliative Care With ALW

If you've been ordered to see a patient in a facility that takes California's Assisted Living Waiver (ALW), two things are different from a private-pay home. The resident has a Care Coordination Agency (CCA) that owns their care plan (the Individualized Service Plan, or ISP), and the facility delivers some personal care under that plan. Your skilled service sits alongside both.

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 service models separate

ALW. The CCA coordinates the approved waiver services and residential support set out in the ALW assessment and ISP.

Home health. Provides ordered, covered skilled services under the home-health benefit and payer rules.

Palliative care. Provides symptom-focused and supportive care under the person's clinical and payer model. It is not hospice and does not require a hospice election.

Facility care. Continues under the facility's license (as an RCFE or ARF), admission agreement and ALW provider responsibilities.

Before services begin

Confirm the order, payer and authorization, service goal, frequency, the clinician, CCA and facility contacts, the participant's authorization, medication and equipment implications, facility access, document exchange, and the escalation process.

Common coordination areas

Area	What to clarify
Skilled nursing	Which skilled tasks the visiting clinician performs, and what facility staff must do between visits
Therapy	How recommendations fit facility staff capability, equipment and the ALW 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 response
Equipment	Ordering provider, payer, delivery, training, and the facility's ability to support safe use
Change in function	It can affect the ALW assessment, tier, ISP and facility fit, tell the CCA, not only the healthcare plan

Avoid duplication

For each service, write down the task, purpose, responsible provider, payer, schedule, facility role, relationship to the ALW ISP and documentation source. Two providers can both be involved without duplicating a payable service, but the distinction must be explicit.

Palliative-care referral questions

Settle what needs are being addressed, who remains the treating clinician, which plan or model the service runs through, what changes the facility and CCA should report, whether advance-care planning is included, whether hospice evaluation may become appropriate later, and the after-hours process.

After hospitalization

Before services resume, verify new orders, medication reconciliation, new equipment, changed function, payer authorization, the facility's ability to support the plan, and whether the CCA needs to reassess.

Your next step

Send the coordination request before the first visit, or call the ALW team. Use a shared contact sheet and a secure route for records; informal texts are how orders get lost.

Coordinate Care With the ALW Team

Call the ALW Team at (747) 293-5777