Policy for Assessing Program Participant Need for Higher Level of Care (HLOC)

1. Policy Statement Family Promise of Puget Sound (FPOPS) is committed to low-barrier, person-centered, and trauma-informed care. FPOPS operates short-term shelter and housing support programs designed to help families and individuals achieve housing stability. While FPOPS strives to serve households with diverse and complex needs, our facilities and staffing are non-clinical and non-medical.

When a program participant presents with medical, physical, cognitive, behavioral, or psychiatric needs that exceed the scope, safety capacity, or functional capabilities of FPOPS programs, FPOPS will conduct a standardized, objective, and trauma-informed assessment to determine if a Higher Level of Care (HLOC) is required. FPOPS will never utilize HLOC assessments to arbitrarily screen out vulnerable households or evade Housing First mandates. Rather, this policy ensures participant safety, respects personal autonomy, explores reasonable accommodations, and facilitates warm, coordinated transfers to appropriate specialized care settings.

2. Purpose

The purpose of this policy is to:

• Establish Clear Assessment Criteria: Standardize how FPOPS staff identify when a participant’s service needs exceed the organizational scope of non-clinical emergency shelter or housing assistance.
• Protect Participant Safety and Wellbeing: Ensure participants receive appropriate, dignified care in settings equipped to meet acute medical, nursing, memory, or psychiatric needs.
• Uphold ADA & Section 504 Standards: Guarantee that interactive reasonable accommodation processes are thoroughly explored before determining a participant cannot be safely served.
• Maintain HUD & CoC Alignment: Ensure full compliance with HUD regulations (24 CFR 576.401/403), Housing First principles, low-barrier access, and Pierce County Coordinated Entry (CE) transfer protocols.
• Prevent Unsafe Discharges: Ensure no participant is discharged into unsheltered homelessness due to elevated medical or behavioral needs without exhaustively attempting supported transitions or crisis intervention.

3. Scope

This policy applies to all staff, case managers, program directors, healthcare liaisons, and management at FPOPS. It covers all program participants enrolled in or applying for FPOPS emergency shelters, temporary warming centers, rapid rehousing, and intensive case management services in Pierce County.

4. Guiding Principles

• Housing First & Low-Barrier Access: Elevated medical, behavioral, or substance use conditions alone do not disqualify an individual from services unless they pose a direct, unmanageable threat to physical safety or exceed standard basic non-clinical care even with reasonable accommodations.
• Trauma-Informed Practice: Assessments are conducted with empathy, transparency, respect, and non-judgment. Behavior is understood as communication, and de-escalation is prioritized.
• Interactive Reasonable Accommodation: Before concluding that an individual requires a higher level of care beyond FPOPS capabilities, FPOPS staff will engage in an interactive dialogue to determine if reasonable adjustments to rules, schedules, physical environment, or supportive services can safely maintain participation.
• Coordination & Warm Handoffs: If a higher level of care is required, FPOPS staff will actively partner with health systems, mobile crisis teams, adult protective services, and Pierce County Coordinated Entry to facilitate a smooth, warm transition.

5. Definitions

• Higher Level of Care (HLOC): Specialized residential, clinical, or medical care settings providing 24/7 skilled nursing, inpatient psychiatric stabilization, memory care, medically monitored detoxification, or licensed assisted living beyond the capacity of a non-clinical shelter or housing provider.
• Activities of Daily Living (ADLs): Basic self-care tasks including bathing, dressing, eating, toileting, mobility, and medication administration.
• Non-Clinical Facility Scope: FPOPS staff provide housing case management, basic shelter, and resource connection; staff cannot administer medications, perform medical procedures, or provide 24/7 line-of-sight psychiatric monitoring.

6. Assessment Criteria & Evaluation Triggers

An assessment for Higher Level of Care is initiated when observable, documented evidence indicates that a participant’s needs exceed non-clinical emergency shelter/housing capacities. Assessment triggers include, but are not limited to:

1. Inability to Perform Essential ADLs independently: Participant cannot perform basic self-care (e.g., severe incontinence, total mobility restriction, inability to feed oneself) in a communal setting, and external home health assistance cannot be arranged or is insufficient.
2. Acute or Unstable Medical Conditions: Medical conditions requiring continuous clinical monitoring, intravenous treatments, daily sterile dressing changes, or specialized medical machinery that FPOPS facilities cannot safely accommodate or power.
3. Severe Cognitive Decline or Dementia: Disorientation or memory loss that leads to repeated unsafe wandering, inability to navigate basic shelter spaces safely, or severe distress that cannot be mitigated in communal housing.
4. Imminent Psychiatric or Behavioral Crisis: Acute psychosis, active suicidal/homicidal ideation, or severe behavioral dysregulation where a participant poses an immediate threat to self or others, requiring immediate clinical stabilization.

7. Evaluation Procedure

Step 1: Observation & Initial Documentation

• When staff observe indicators of HLOC needs, they document specific, objective behaviors or medical occurrences in the participant’s case file (or HMIS record, adhering to FPOPS confidentiality guidelines).
• Staff must avoid subjective labeling or assumptions regarding diagnoses.

Step 2: Interactive Reasonable Accommodation Review

• The Case Manager and Program Director meet to evaluate potential accommodations.
• Assessment Questions:
  • Can visiting healthcare services (e.g., Visiting Nurse, Home Health, Community Health Workers) bridge the care gap?
  • Can adaptive equipment or environmental adjustments resolve the safety concern?
  • Can schedule modifications or care planning accommodate the participant’s needs?

Step 3: Multi-Disciplinary Care Consultation

If reasonable accommodations within FPOPS scope are insufficient:

• The Case Manager schedules a multi-disciplinary case conference with the participant, FPOPS leadership, local healthcare partners, behavioral health providers, and family/emergency contacts (with signed Release of Information).
• The team evaluates functional capacity using standardized assessment tools (e.g., ADL checklists, clinical intake notes from treating physicians).

Step 4: Participant Engagement & Choice

• Staff discuss evaluation findings directly with the participant in a private, supportive, trauma-informed setting.
• Staff outline care options, emphasizing participant autonomy and consent throughout the process.

8. Referral, Transfer, and Separation Protocols

If a Higher Level of Care is determined necessary for participant safety and health:

[Assessment Identifies HLOC Need] 
          │
          ▼
[Interactive Reasonable Accommodation Analysis] 
          │
  ┌───────┴────────┐
  ▼                ▼
[Accommodated]  [Requires HLOC Transfer]
  │                │
  ▼                ▼
[Maintain In     [Coordinate Warm Transfer] ──► [Pierce County Coordinated Entry /
 FPOPS Program]   │                            Health System / Specialized Facility]
                  ▼
                [Bed Hold / Program Transition Plan]

1. Non-Emergency Care Transfers:
   • Warm Handoff: Case management initiates direct outreach to appropriate HLOC facilities (e.g., skilled nursing facilities, permanent supportive housing with 24/7 nursing, assisted living, inpatient behavioral health).
   • Coordinated Entry Integration: Staff notify Pierce County Coordinated Entry (CE) to update prioritization status or request emergency transfer assistance.
   • Bed-Hold Policy: For temporary medical hospitalizations or short-term residential treatment (e.g., 30 days or fewer), FPOPS will hold the participant’s shelter cot/housing placement whenever feasible to maintain continuity upon discharge.
2. Emergency / Acute Crisis Interventions:
   • If a participant experiences an acute medical emergency or severe behavioral health crisis posing immediate danger, staff will contact emergency medical services (911/Crisis Line) or request a welfare check in accordance with FPOPS Welfare Check Protocols.
   • Staff will notify program leadership immediately and conduct follow-up outreach with hospital social workers to plan safe post-discharge housing.
3. Due Process & Written Notice:
   • If an HLOC determination requires separation from an FPOPS shelter or housing program, the participant will receive written notice detailing the safety/medical reasons for transition, available transfer resources, and instructions for filing an appeal.
   • Involuntary transfers adhere strictly to FPOPS Separation and Termination procedures.

9. Participant Appeals Process

Participants have the right to appeal any determination that requires their transition out of FPOPS programs due to HLOC requirements:

1. Filing an Appeal: The participant (or designated advocate) may submit a verbal or written appeal to the FPOPS Chief Executive Officer within 24–48 hours of receiving written notice.
2. Review: The CEO reviews the clinical/medical documentation, assessment notes, and reasonable accommodation exploration.
3. Final Decision: A prompt written decision is provided to the participant within 48 hours. During non-safety-related appeals, program status is maintained where feasible.

10. Roles and Responsibilities

Role	Primary Responsibilities
Case Managers / Shelter Staff	Identify and document functional/medical needs; explore reasonable accommodations; coordinate with external healthcare providers and Pierce County Coordinated Entry; facilitate warm handoffs.
Program Directors	Oversee HLOC evaluation reviews; ensure non-discrimination and ADA compliance; approve transfer plans and issue written notices.
Chief Executive Officer (CEO)	Holds ultimate administrative authority over policy implementation, systemic compliance, and final appeal determinations.

11. Confidentiality & Data Privacy

All medical records, assessment forms, and interdisciplinary team notes gathered during an HLOC evaluation are strictly confidential under federal (HIPAA, Privacy Act), Washington State law, and FPOPS Confidentiality & HMIS Release Policies. Information is shared strictly on a need-to-know basis with explicit written consent, except where mandated by law.

12. Policy Review and Revision

This policy is reviewed annually by the CEO and Board of Directors[cite: 1] to maintain alignment with HUD grant requirements, Pierce County CoC standards, Fair Housing mandates, and clinical best practices