ALW Nursing Facility Transition Care Coordination

The transitional care benefit is designed primarily to address the need for care coordination prior to the successful transition of an individual from a skilled nursing or
institutional setting into an assisted living setting.

As healthcare expenditures rise at an unsustainable rate there is increasing focus by patients, providers, and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations and re-institutionalizations. Poor coordination of care across settings often results in re-hospitalizations or reinstitutionalizations, many of which are avoidable.

Transitions in care after hospitalization or institutionalization involve both a smooth transition out of the hospital, skilled nursing, or institutional setting, as well as an activated and reliable reception into the next setting of care. Care Coordination Agencies enrolled as providers in the Assisted Living Waiver program are professionals dedicated to the care of individuals faced with changing health care needs.

*Information from

We are Norcal Care Coordinator Agency.

A care management company that specializes in the placement of Medi-Cal eligible patients into assisted living facilities under the Medi-Cal ALWP guidelines.