Acute Care Hospitals

Hands holding


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 ( 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 is implementing a Guardianship pilot project that will target a smaller number of individuals for assistance with identifying Certified Public Guardians/Conservators.

Acute Care Hospital Referral Resources


Regional contacts will be periodically updated as Guardianship Case Managers are identified.

Guardianship Pilot Project Information & Forms

Guardianship Pilot Project Regional Contacts

contact 1Program Manager
Sarah Tremblay
contact region 1Region 1
Melanie Thomason
contact region 2Region 2
Marissa Heeley
contact region 3Region 3
Christine Romo

Guardianship Pilot Project Contractor Resources

  1. COVID Declaration
  2. State Form A-19 Invoice Voucher (Excel Document) and Instructions Sheet (Word Document)
  3. CPGC Monthly Billing Report Template
  4. HCS CPGC Quarterly Report Template
  5. HCS Guardianship Pilot Project Contractor Eligibility

Guardianship Pilot Project Contractor Contacts

contact GuardianshipProgram Manager
Sarah Tremblay

contact GuardianshipRegion 1
Amy Depaolo

contact GuardianshipRegion 2
Kendra Kruse
contact GuardianshipRegion 2
Angelique Johnson
contact GuardianshipRegion 3
Heather Chappell


Training Resources

  1. 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. 
  2. Audio recording of the Acute Care Hospital Staff Training: Guardianship pilot training & referrals (YouTube video)
  3. Q & A of the Acute Care Hospital Staff Training: Guardianship pilot training & Referrals.
  4. Acute Care Hospital Staff 101 Training (YouTube Video): 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.
  5. Consent, Capacity and Guardianship Frequently Asked Questions