Background
Home and Community Living Administration (HCLA) coordinates transitions with acute care hospitals statewide as well as border hospitals, state hospitals and community psychiatric facilities. Many patients 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.
HCS Partners with individuals connecting them with person centered services to achieve timely transitions to home and community-based settings and reduce avoidable inpatient stays. Effective transitioning planning and collaboration is essential among HCS staff, institutional settings, managed care organizations, service providers, and community partners.
Refer to Chapter 9 of the long-term care manual for HCS policies and procedures on inpatient hospital assessments and transitions.
Resources for Inpatient Settings
- HCS Referral Guide for Inpatient Settings
- DSHS Intake and Referral Intake Form for Functional Assessment
- Medicaid Application for aged, blind, disabled/long-term care coverage (PDF)
- * Hospital Certification of Potentially Disabling Condition
- * Expedited Acute Hospital Application Chart and Cover Letter
- LTC Setting and in-home Dialysis Guide
- HCS Decision Making for Transitions
- HCS Escalation Contacts (Updated Jan 2026)
- State-funded long-term care for noncitizens | Washington State Health Care Authority
- Nurse Delegation Reference Sheet - Frequently Asked Questions
- Transitional Care Center of Seattle
- HCLA - 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.
- HCLA - 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.
* Resource is specific to Acute Care Hospitals only.
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.
Cross System Care Coordination Resources
- Cross System Care Coordination - Eligibility and MCO look up resources (DSHS)
- Billers, providers, and partners | Washington State Health Care Authority
- Successful eligibility checks using ProviderOne | Washington State Health Care Authority