Background
Many acute care hospital patients who are referred to the Department’s Home and Community Services (HCS) division are new to long-term care services and will require a functional and/or financial eligibility determination. Ensuring timely transitions to services is essential in reducing the number of days patients spend in acute care settings when they no longer meet medical necessity. Aging and Long-Term Support Administration must coordinate transitions with border acute hospitals and more than 50 acute care hospitals statewide. Successful transition planning involves strong collaboration and partnership with regional staff, hospitals, managed care organizations, providers, and communities, to provide appropriate services and community options that honor patient choice and reduce medical costs while increasing individual wellbeing, and quality of life.
Refer to Chapter 9a.docx (live.com) of the long-term care manual for details of HCS policies and procedures on acute care hospital assessments.
A smaller group of individuals referred to HCS for long-term care services deal with multi-faceted barriers such as extensive criminal history, complex behavior challenges, medical complexity, bariatric, lack of decision maker, and/or not meeting Medicaid financial eligibility making the transition more complicated and time intensive. To reduce some of the pressure on an already strained healthcare system, DSHS in partnership with acute care hospitals implemented a Guardianship pilot project which targeted a smaller number of individuals for assistance with identifying Certified Public Guardians/Conservators.
Given the successful outcomes of the pilot project, DSHS has transitioned the pilot project to a program. The program will be a state-funded program called the HCS Guardianship and Conservatorship Assistance Program (GCAP). GCAP becomes effective September 1, 2024. Information pertaining to GCAP may be found in Chapter 388-106-2100 WAC.
Acute Care Hospital Referral Resources
- HCS Referral Guide for Acute Hospitals
- DSHS Intake and Referral Intake Form 10.570
- Application for aged, blind, disabled/long-term care coverage (PDF)
- Hospital Certification of Potentially Disabling Condition
- Expedited Acute Hospital Application Chart and Cover Letter (November 2023)
Hospital Trainings
- Financial Eligibility for Long Term Service Supports (24:15) This training is an overview of financial eligibility for Long-Term Services and Supports which will review the application process, client responsibility, spenddowns, spousal allocation, fast track, presumptive eligibility, and penalty period.
- Home and Community Services Intake Care Assessment (26:52) This training provides an overview for acute care hospitals on how to make an HCS referral and CARE assessment considerations, such as ADLs, IADLs, treatments, behaviors, look back periods and informal supports
- Home and Community Services Client Choice and Rights 18:32) Home and Community Services is not a healthcare provider and therefore must follow Medicaid laws around person centered planning. This training focuses on client choice and rights in Home and Community Based Settings.
- Home and Community Services In Home Services and Programs (25:04) Training focused on Home and Community Services programs and services available to clients requesting in home care, an overview of behavioral health wrap around supports, Fast Track and Presumptive Eligibility.
- Home and Community Services Residential Settings and Programs (29:50) Training focused on Home and Community Services programs available to clients requesting residential care. Discusses the difference between residential settings and an overview of behavioral health and dementia related programs.
- Hospital Staff Training It clarifies roles for both hospital staff and HCS staff, assists hospital staff in establishing Medicaid eligibility and describes process for development of a plan of care.
Resources
- LTC Setting and in-home Dialysis Guide
- HCS Decision Making for Transitions
- HCS Escalation Contacts (Updated Feb 2025)
- State-funded long-term care for noncitizens | Washington State Health Care Authority
- 2023 LTSS PE Fact Sheet for Acute Care Hospitals
- LTSS Presumptive Eligibility Program
- Nurse Delegation Reference Sheet - Frequently Asked Questions
- Transitional Care Center of Seattle
- Audio recording of the Acute Care Hospital Staff Training: Guardianship pilot training & referrals (YouTube video) Acute Care Hospital Staff Training: Guardianship pilot training and referrals—This training is designed to outline the purpose, eligibility criteria, and referral process for the Guardianship pilot. Also clarifies roles for both acute care hospital staff and HCS staff in coordinating transitions to Long-term care services.
- Q & A of the Acute Care Hospital Staff Training: Guardianship pilot training & Referrals.
- Consent, Capacity and Guardianship Frequently Asked Questions
- ALTSA - How to Identify a Guardian: This is a resource tool designed to outline the process of identifying a person to serve as guardian and/or conservator for individuals who no longer have capacity to consent to services and have no legal decision-maker identified. A person must be identified for nomination as proposed guardian and/or conservator to file a legal motion with the court. This resource tool also explains the process of identifying a proposed nominee utilizing alternative programs such as GCAP and Office of Public Guardians (OPG) as both are distinct and separate programs with their own eligibility criteria and governing laws.
- ALTSA - Power of Attorney vs. Uniform Guardianship: This is a resource tool designed to overview available court processes to explore identification of an alternative decision maker for individuals who no longer have capacity to consent to services themselves. This resource tool explains the differences between the Power of Attorney Act and the Uniform Guardianship, Conservatorship, and Other Protective Arrangements acts and the legal remedies that can be provided under each motion type.
Cross System Care Coordination Resources
Guardianship and Conservatorship Assistance Program (GCAP) Information and Forms
- Guardian Conservator Search Form (PDF)
- Due Diligence Checklist
- GCAP Referral Form
- GCAP Referral Process Overview
- GCAP Eligibility Criteria, Referral Process, and Program Details (WAC 388-106-2100)
- HCS Guardianship Pilot Project- 1 Year Summary