Divine Agape Health Care Agency Referral Form
  • Personal Care & Homemaker Services

  • Personal Care and Homemaker Services (PCHS) support individuals who need help with:
    Activities of Daily Living (bathing, dressing, toileting, ambulation, feeding) and Instrumental Activities of Daily Living (meal preparation, grocery shopping, money management).
    These services closely align with those offered by the In-Home Supportive Services (IHSS) program and may include:

    • Housekeeping (cleaning, laundry)
    • Meal preparation
    • Shopping assistance
    • Personal care (bathing, grooming, bowel/bladder care, paramedical services)
    • Accompaniment to medical appointments
    • Supervision for individuals with cognitive or mental impairments

    Program overview

    PCHS helps individuals remain safely in their homes and may be authorized in the following scenarios:

    • During the IHSS application process: Including any waiting period after a referral. PCHS may be approved before IHSS services begin.
    • Supplemental support: When IHSS hours are insufficient or exhausted.
    • IHSS-ineligible individuals: To prevent short-term skilled nursing facility stays (up to 60 days).

    Note: For short-term PCHS, members are not required to apply for IHSS. However, authorization requests must document the risk of institutionalization without PCHS.

    Eligibility

    Individuals may qualify for PCHS if they:

    • Are at risk of hospitalization or institutionalization in a nursing facility.
    • Have functional impairment and lack adequate support.
    • Are approved for IHSS.

    Coordination with IHSS and Home and Community-Based Alternatives (HCBA) Waiver

    IHSS as primary support: PCHS supplements IHSS when authorized hours are insufficient.

    • HCBA waiver coordination: Waiver Personal Care Services (WPCS) under HCBA must be managed separately to avoid duplication.
    • Eligibility restrictions: Individuals receiving WPCS through HCBA are not eligible for PCHS. However, those on the HCBA waitlist may receive PCHS until waiver approval.

    Restrictions

    • PCHS cannot replace IHSS referrals. Eligible members must be referred to IHSS
    • If a member's condition changes, they must be reassesssed for IHSS. PCHS may continue during the reassessment period.

    Authorization:

    • Initial authorization: Based on assessed need; maximum duration is 60 days.
    • Authorization extension: 
      • IHSS denial: One-time 60-day authorization; no extensions.
      • Other needs: Submit reassessment and request every 30 days until IHSS is approved, a caregiver is identified or alternative care is arranged.
  • Referring Provider Information

  • Format: (000) 000-0000.
  • Date of Referral*
     - -
  • Member Information

    Please complete members information
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Service Request

  • Level of Urgency*
  • Services requested*
  • IHSS Status

  • Current support & caregiver situation

  • Is Respite Care requested to provide relief for the caregiver?
  • Functional needs & ADL/IADL assessment

  • Activities of Daily Living (ADLs) — check all that apply
  • Instrumental Activities of Daily Living (IADLs) — check all that apply
  • Risk of institutionalization*
  • Additional Notes

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  • Disclaimer and Acknowledgment

    The information provided above has been obtained to the best of my ability. The member has been informed and acknowledges that Divine Agape Health Care Agency may contact and notify the Manage Care Plan and the client regarding the requested services. While criteria are established by DHCS, services may or may not be approved by the Mange Care Plan (MCP). The client must meet the criteria set forth by DHCS, which include:

     

    • During the IHSS application process, including during any waiting period after a referral has been made. PCHS may be authorized prior to, and up until, IHSS services are in place.

    • In addition to any approved county IHSS hours when additional support is required, including when IHSS benefits are exhausted.

    • For Members who are ineligible for IHSS, PCHS can be put in place to help prevent a short-term stay in a skilled nursing facility (not to exceed 60 days). In order to receive short term PCHS, Members are not required to apply for IHSS, but the authorization request should include information about the need for short term stay in a skilled nursing facility in the absence of  PCHS being available. 

  • Today's Date*
     - -
  • Urgency Level*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Relation to member
  • Format: (000) 000-0000.
  • Risks
  • Member needs help with: (ADLs)
  • Member needs help with: (IADLs)
  • Types of Services*
  • Should be Empty: