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Program Information & Acknowledgment

The Connections Care Home Consultants application portal for the California Advancing and Innovating Medi-Cal (CalAIM) Community Support for Assisted Transitions (SNF Diversion/Transition) for Health Net and Kaiser.

MCP: Managed Care Plan

RCFE: Residential Care Facility for the Elderly

ARF: Adult Residential Facility

CalAIM: California Advancing and Innovating Medi-Cal

SNF: Skilled Nursing Facility

ISP: Individual Service Plan

CS: Community Supports

SOC: Share of Cost

What is the California Assisted Living and Innovating Medi-Cal (CalAIM) Program?

CalAIM is California's long-term initiative to transform the Medi-Cal program by improving quality outcomes, reducing health disparities, and creating a more seamless and consistent system. It aims to achieve this through a focus on "whole person care," which includes addressing social determinants of health, integrating physical, mental, and social services, and launching new programs like Enhanced Care Management (ECM) and Community Supports. Community Supports (CS) are administered through managed care plans (MCPs).

Community Supports for Assisted Living Transitions

There are 14 Community Supports (CS) and Assisted Living Transitions is one of them. This CS gives eligible members the choice to reside in an assisted living setting—such as a Residential Care Facility for the Elderly (RCFE) or an Adult Residential Facility (ARF)—as a safe alternative to a skilled nursing facility, promoting greater independence and community integration.

The Role of Connections Care Home Consultants

Connections is a CS Provider that assists with understanding the program, finding participating facilities, coordinating paperwork and assessments, and liaising with your Managed Care Plan to request authorization for the CS. Once a member is placed, we also send a MSW to visit the member at the RCFE/ARF for monthly quality control checks and provide ongoing care coordination.

Managed Care Plans We Work With

  • Health Net: Serving members in Sacramento and Los Ángeles counties.
  • Kaiser Permanente: Serving members in various counties throughout California.

You must be a member of one of these plans to utilize our services for the CalAIM Community Support for Assisted Living Transitions.

Types of Assisted Living (RCFEs/ARFs)

Assisted living facilities in California (also known as residential care facilities for the elderly - RCFEs) come in various sizes, each offering a different environment. Connections can help you find a setting that best suits your needs:

  • Small, Home-Like Settings: These are typically 4-6 bed homes that provide a high staff-to-resident ratio. This environment offers more personalized attention and a quieter, more intimate living experience.
  • Large, Community Settings: These are often 100+ bed facilities that feature amenities like group dining rooms, a wide variety of planned activities, and social opportunities. Staff is available as needed to provide care and support.

ARF vs. RCFE: What's the Difference?

In California, the key difference between an Adult Residential Facility (ARF) and a Residential Care Facility for the Elderly (RCFE) is the age of the residents they serve. ARFs provide non-medical care and supervision to adults aged 18 to 59, often with disabilities or other conditions. RCFEs, on the other hand, are specifically for individuals 60 years and older who need assistance with daily living activities.

CS Member Summary

This form gathers essential information about the member to determine eligibility for the CalAIM Community Supports program.

Member Information

This is a 9 character number starting with '9' and ending with a letter.

For Health Net use the same Medi-Cal number. For Kaiser this is not the Medi-Cal number but a distinct number oftentimes starting with some zeros.

e.g., English, Spanish

Your Information (Person Filling Out Form)

(xxx) xxx-xxxx

If not applicable, leave blank.

Primary Contact Person

(xxx) xxx-xxxx

Secondary Contact Person (Optional)

(xxx) xxx-xxxx

Legal Representative

A legal representative (e.g., with Power of Attorney) is distinct from a contact person. If the legal representative is also the primary or secondary contact, please enter their information again here to confirm their legal role.

Does member have capacity to make their own decisions?

Does member have a legal representative? (e.g., power of attorney)

Representative's Contact Info

If the member does not have a legal representative, you can leave these fields blank.

(xxx) xxx-xxxx

Location Information

Member's Current Location

Current Address

Customary Residence (where is the member's normal long term address)

Health Plan & Pathway

Health Plan (Managed Care Plan)

Will member be switching Health Plan by end of month?

Pathway Selection

SNF Transition Eligibility Requirements

Enables a current SNF resident to transfer to a RCFE or ARF.

  • Has resided in a SNF for at least 60 consecutive days (which can include a combination of Medicare and Medi-Cal days and back and forth from SNF-hospital-SNF); and
  • Is willing to live in RCFE as an alternative to a SNF; and
  • Is able to safely reside in RCFE with appropriate and cost-effective supports and services.

SNF Diversion Eligibility Requirements

Transition a member who, without this support, would need to reside in a SNF and instead transitions him/her to RCFE or ARF.

  • Interested in remaining in the community; and
  • Is able to safely reside in RCFE with appropriate and cost-effective supports and services; and
  • Must be currently at medically necessary SNF level of care: e.g., require substantial help with activities of daily living (help with dressing, bathing, incontinence, etc.) or at risk of premature institutionalization; and meet the criteria to receive those services in RCFE or ARF.

ISP & Facility Information

Individual Service Plan (ISP) Contact

(xxx) xxx-xxxx

ISP Assessment Location

Type of Location

Assisted Living Waiver (ALW) Status

Is the member currently on the ALW waitlist?

RCFE Selection

Has a preferred assisted living facility (RCFE) been chosen?

Preferred Facility Details

If a facility has not been chosen, you can leave these fields blank.

(xxx) xxx-xxxx

HIPAA Authorization Form

Authorization for Use or Disclosure of Protected Health Information (PHI).

Patient Information

For Health Net use the Medi-Cal number (starts with 9). For Kaiser use their specific MRN.

This form, when completed and signed by you, authorizes the use and/or disclosure of your protected health information. The information authorized for release may include information related to HIV/AIDS, mental health, and substance use, unless specified otherwise.

Person(s) or organization(s) authorized to make the disclosure:

any health care related agency or person providing information for the purpose of applying for the CalAIM CS for Assisted Living Transitions

Person(s) or organization(s) authorized to receive the information:

Connections Care Home Consultants, LLC

Specific information to be disclosed:

All medical records necessary for Community Supports (CS) application.

The information will be used for the following purpose:

To determine eligibility and arrange services for CS for Assisted Living Transitions.

This authorization expires:

One year from the date of signature.

My rights:

I understand that I may refuse to sign this authorization. My healthcare treatment is not dependent on my signing this form. I may revoke this authorization at any time by writing to the disclosing party, but it will not affect any actions taken before the revocation was received. A copy of this authorization is as valid as the original. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Redisclosure:

I understand that the person(s) or organization(s) I am authorizing to receive my information may not be required to protect it under federal privacy laws (HIPAA). Therefore, the information may be re-disclosed without my consent.

Sensitive Information

This includes information related to substance abuse, mental health conditions, and HIV/AIDS.

Do you authorize the release of sensitive information?

Signature

By signing below, I acknowledge that under penalty of perjury, I am the member or an authorized representative legally empowered to sign on behalf of the member.

I am the:

Participant Liability Waiver & Hold Harmless Agreement

Please carefully review the following liability waiver and sign below.

For Health Net use the Medi-Cal number (starts with 9). For Kaiser use their specific MRN.

Intention. The purpose of this agreement ('Agreement') is to forever release and discharge Connections Care Home Consultants, LLC (the 'Company') and all its agents, officers, and employees (collectively referred to as 'Releasees') from all liability for injury or damages that may arise out of the resident/client's ('Resident') participation in the Community Supports program ('Program'). Resident understands that this Agreement covers liability, claims, and actions caused in whole or in part by any acts or failures to act of the Releasees, including, but not limited to, negligence, fault, or breach of contract.

Release and Discharge. Resident does hereby release and forever discharge the Releasees from all liability, claims, demands, actions, and causes of action of any kind, arising from or related to any loss, damage, or injury, including death, that may be sustained by Resident or any property belonging to Resident, whether caused by the negligence of the Releasees or otherwise, while participating in the Program, or while in, on, or upon the premises where the Program is being conducted, or while in transit to or from the Program.

Assumption of Risk. Resident understands that their participation in the Program may involve a risk of injury or even death from various causes. Resident assumes all possible risks, both known and unknown, of participating in the Program and agrees to release, defend, indemnify, and hold harmless the Releasees from any injury, loss, liability, damage, or cost they may incur due to their participation in the Program.

Indemnification. Resident agrees to indemnify, defend, and hold harmless the Releasees from and against all liability, claims, actions, damages, costs, or expenses of any nature whatsoever for any injury, loss, or damage to persons or property that may arise out of or be related to Resident's participation in the Program. Resident agrees that this indemnification obligation survives the expiration or termination of this Agreement.

No Insurance. Resident understands that the Company does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance, in the event of injury or illness. Resident understands that they are not covered by any medical, health, accident, or life insurance provided by the Company and is responsible for providing their own insurance.

Representations. Resident represents that they are in good health and in proper physical condition to safely participate in the Program. Resident further represents that they will participate safely and will not commit any act that will endanger their safety or the safety of others.

Acknowledgment. Resident acknowledges that they have read this Agreement in its entirety and understands its content. Resident is aware that this is a release of liability and a contract of indemnity, and they sign it of their own free will.

Signature

By signing below, I acknowledge that under penalty of perjury, I am the member or an authorized representative legally empowered to sign on behalf of the member.

I am the:

Freedom of Choice Waiver

Acknowledge your choice regarding Community Supports services.

For Health Net use the Medi-Cal number (starts with 9). For Kaiser use their specific MRN.

I understand I have a choice to receive services in the community. Community Supports for Community Transition are available to help me. I can choose to accept or decline these services.

If I accept these services, I will receive assistance from Connections Care Home Consultants to move into a community-based setting like an assisted living facility. They will help me find a place, coordinate paperwork, and ensure I am settled in. This will be authorized and paid for by my Managed Care Plan.

If I decline these services, I am choosing to remain where I am, and I will not receive the transition support services offered by this program at this time.

My Choice

Signature

By signing below, I acknowledge that under penalty of perjury, I am the member or an authorized representative legally empowered to sign on behalf of the member.

I am the:

Declaration of Eligibility

This form is for a Physician/AP to establish presumptive eligibility and must be signed by the member's Primary Care Provider (PCP) or a provider with an established relationship with the member.

To be completed by the Primary Care Provider (PCP) or other physician/practitioner (practitioner).

I, , in the professional capacity as a , affirm that Member is currently receiving a medically necessary Skilled Nursing Facility Level of Care (SNF LOC) or meets the minimum criteria for receiving SNF LOC services and, in lieu of entering a facility, is choosing to remain in the community and continue receiving medically necessary SNF LOC services in an assisted living facility for the following reason(s):

For Health Net use the Medi-Cal number (starts with 9). For Kaiser use their specific MRN.