The Home and Community Living Administration coordinates transitions with acute care hospitals statewide, as well as border hospitals, state hospitals, and community psychiatric facilities. Many patients referred to the Home and Community Services division are new to long-term care services and will require a functional and/or financial eligibility determination.
Home and Community Services partners with people, connecting them with person-centered services to achieve timely transitions to home and community-based settings and reduce avoidable inpatient stays. Effective transition planning and collaboration are essential among Home and Community Services staff, institutional settings, managed care organizations, service providers, and community partners.
Refer to Chapter 9 of the long-term care manual for Home and Community Services 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 (DSHS 10-570 PDF)
- Medicaid Application for aged, blind, disabled/long-term care coverage (HCA 18-005 PDF)
- Hospital Certification of Potentially Disabling Condition* (HCA 19-0054 PDF)
- Expedited Acute Hospital Application Coversheet (Word)*
- Long-Term Care Setting and in-home Dialysis Guide (PDF)
- Home and Community Services Decision Making for Transitions (PDF)
- Home and Community Escalation Contacts PDF (Updated Jan 2026)
- State-funded long-term care for noncitizens | Washington State Health Care Authority
- Nurse Delegation Reference Sheet - Frequently Asked Questions (PDF)
- Transitional Care Center of Seattle (PDF)
- HCLA - How to Identify a Guardian (PDF)
Resource tool designed to outline the process of identifying a person to serve as guardian and/or conservator for people who no longer have capacity to consent to services and have no legal decision-maker identified. - HCLA - Power of Attorney vs. Uniform Guardianship (PDF)
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.
* Resource is specific to acute care hospitals only.
Hospital Trainings
- Financial Eligibility for Long Term Service Supports (24:15)
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)
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
- Billers, providers, and partners | Washington State Health Care Authority
Successful eligibility checks using ProviderOne | Washington State Health Care Authority (PDF)