ALW referral quick reference for case managers

The Assisted Living Waiver (ALW) cannot meet a discharge date. The state controls when waiver slots open, so keep your safe discharge plan running. ALW can still be the right long-term plan for a patient who needs nursing-facility level of care and could live safely in assisted living. Beta is a Care Coordination Agency (CCA), the state-listed organization that does the ALW paperwork and care planning with the applicant.

When a referral is worth making

Refer when most of these are true or possible:

the patient is 21 or older
full-scope Medi-Cal is active or being verified, and the share of cost is zero or the county is resolving it
nursing-facility level of care looks plausible
the patient could be supported safely in an assisted-living facility that takes ALW
the patient prefers assisted living to a nursing facility
the patient is willing to live in one of the fifteen ALW counties

The fifteen ALW counties are Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma. Beta coordinates ALW care in all of them.

You do not need to confirm eligibility first. The county decides Medi-Cal eligibility. The California Department of Health Care Services (DHCS) decides ALW eligibility after a nurse assessment. A referral is a screen, not an eligibility decision.

The current setting matters

Setting	What to have ready
Nursing facility or other institutional setting	The admission date and the discharge-planning contact. At least 60 days in an institutional setting when the waitlist request is submitted puts the patient in the first priority group.
Hospital	The prior setting, the likely next setting, and whether a nursing facility stay is planned.
Home or community	The current risks, the supports in place and where the patient wants to live. Community applicants come after the priority groups.
A participating RCFE or ARF already	Whether the facility takes ALW. The state's existing-resident checklist (DHCS 1331) applies.

What to have for the call

your organization, role and callback number
the patient's current setting and county
the admission date, if the patient is in a nursing facility or other institutional setting
Medi-Cal status, as far as you know
the general need, in one or two sentences
who makes decisions with or for the patient, and whether they agree to the referral

That is enough. Beta takes the referral by phone and asks for anything else on the call. Do not send names, records, Social Security numbers or clinical details by email. If records are needed, Beta tells you how to send them. The full list is on the referral checklist.

What happens next

Beta takes the referral by phone and talks with the patient or their representative about whether ALW may fit.
If the patient wants to go ahead, Beta screens the waitlist request within seven calendar days. Beta confirms it in writing within three calendar days after screening. DHCS keeps the master waitlist.
DHCS releases slots in priority order, when the state releases capacity. The first group is people with at least 60 days in an institutional setting. Next come people with an Adult Protective Services referral, then people with a Long-Term Care Ombudsman referral, then everyone else. Those referrals are priority groups under DHCS policy, not a way to move someone up the list.
When DHCS releases a slot, a Beta nurse assesses the patient, writes the care plan (the Individualized Service Plan) and collects the enrollment documents. For a move from a nursing facility, the items are on the state's DHCS 1327 checklist. DHCS decides eligibility. Beta generally has 60 days from the slot notice to submit the complete application.
The patient chooses a home on the state's list. Participation means the home is on that list. Whether it has a room, admits the patient and can meet the care plan are the home's own answers, separate from the slot.

Boundaries. Beta can screen, coordinate, assess and follow up. Beta cannot promise eligibility, an expedited slot, a wait time, approval, a care tier, facility acceptance or a move-in date.

Refer

Refer a patient or client at alwbeta.com/refer
Call (747) 293-5777
Read what happens after a referral and ALW referrals from a hospital or SNF

In an emergency, call 911.

Sources

The current version of this sheet is at alwbeta.com/resources/social-worker-quick-reference.