Who Should Refer
We work directly with the teams who need beds for patients that are hard to place:
- Hospital discharge planners and case managers — especially for high-acuity or complex discharges with a short timeline
- Skilled nursing and post-acute coordinators — when a patient needs to step up or step down between levels of care
- Hospice and transitional-care teams — when a patient needs an AFH bed that can support a specific care plan
- Long-term-care referral coordinators — when prior facilities have declined the patient
If you're not sure whether we can help, call us. We'll tell you straight whether your case fits our network — and if it doesn't, we'll point you to the resources that can.
Why Discharge Planners Work With Us
You know the frustration: a patient needs to be discharged, but facility after facility says no. The patient is too complex, too heavy, too medically fragile. Meanwhile, the bed is needed, the family is stressed, and the clock is ticking.
We solve this problem. Our network specializes in adult family homes that accept high-acuity patients — the ones everyone else turns away.
We Take the Hard Cases
Ventilator-dependent, tracheostomy, bariatric, dialysis — we have homes in our network equipped for complex medical needs. Stop calling facilities that will say no.
Urgent Referrals Prioritized
We understand hospital bed pressure. When you call with an urgent case, we prioritize it and keep you updated — no radio silence.
Direct Access
No call centers. No phone trees. You'll have our direct numbers. When you call with an urgent case, someone answers.
Pre-Qualified Matches
We don't send you a list of 50 facilities to call. We identify a shortlist of homes that can actually accept your patient's level of care and have current availability.
We Handle the Details
From coordinating tours to managing paperwork, we take the administrative burden off your plate so you can focus on patient care.
We Make You Look Good
Successful placements reflect well on everyone. We follow up to ensure they stick, and we're accountable if issues arise.
Difficult-to-Place Clinical Needs We Help Coordinate
We've specifically built our network for patients with complex medical needs — the cases general placement agencies can't cover:
Clinical Needs We Commonly Place
- Ventilator-Dependent — Homes with respiratory support and 24/7 monitoring, typically under a Private Duty Nursing (PDN) arrangement.
- Tracheostomy Care — Skilled trach management, suctioning, and emergency response.
- Bariatric Patients — Homes with appropriate equipment, lift capacity, and transfer assistance for larger patients.
- Dialysis — Coordination with dialysis centers, transportation, and management of complex schedules.
- Complex Wound Care — Pressure injuries, surgical wounds, and specialized dressing changes.
- G-Tube / J-Tube — Enteral feeding management and monitoring.
- IV / Antibiotic Therapy — Homes that support IV medication administration.
- Memory Care with Behavioral Needs — Secured environments for wandering, behavioral challenges, and advanced dementia.
- Pre-Medicaid Planning — Placement that anticipates a transition to Medicaid funding.
Every case is different. If a patient's needs aren't on this list, call us anyway — we'll assess whether a home in our network can be set up to support them.
What Happens After Referral
1. We Take the Referral
Call or submit the referral form with the patient's clinical needs, timeline, and payer. For PHI-containing referrals, use the direct line and we'll walk you through intake.
2. We Evaluate and Match
We confirm the care needs, verify eligibility and licensing, and shortlist homes that can actually accept this patient — based on capability, availability, and fit, not just geography.
3. We Coordinate the Transition
We schedule tours for the family, facilitate communication, and coordinate the logistics of the move-in with the home and the referring team.
4. We Follow Up
We check in after placement to catch issues early and support the patient and family through the transition.
Response Expectations
We treat urgent referrals as a priority and keep you informed throughout. As a general expectation: we acknowledge urgent referrals the same day, commonly identify a shortlist of matching homes within 24–72 hours, and coordinate tours and move-in from there. Timing varies by patient acuity, home availability, funding determination, and provider acceptance — we don't guarantee a specific timeline, and we'll be honest if a case is likely to take longer.
What We Evaluate Before Presenting an Option
Before we present a home to you or the family, we confirm it can actually support the patient:
- Current Washington license in good standing with DSHS
- Real, current availability — an open bed, not a hopeful maybe
- Equipment and physical setup — room, power, lift capacity, safe layout for the required equipment
- Staffing and training — experience with the specific care level, including PDN arrangements where required
- Prior experience — whether the home has successfully cared for patients at this acuity
- Location and fit — proximity for the family and access to required services such as dialysis centers
Final Acceptance Is the Provider's Decision
A few things stay squarely with the provider and their clinical team:
- Acceptance is always the home's call. A home we present still performs its own admission review and makes the final decision.
- Clinical review comes first. The home's nurse or administrator reviews the patient's records and confirms the home can safely meet the care plan before any admission.
- Funding approval. For Medicaid or PDN cases, DSHS assessment and funding decisions are made by the appropriate agencies and providers — we help coordinate, but we don't control those determinations.
We're upfront about these constraints because they matter for discharge planning. We'd rather set realistic expectations than over-promise a bed.
Required Referral Information
To match as quickly as possible, please provide what you can from the checklist below. The more clinical detail you can share up front, the faster and more accurate our matching will be.
Referral Checklist
- Face sheet — Patient demographics and current location
- History and physical — Current H&P or recent discharge summary
- Medication list — Current medications, dosages, and schedule
- Current nursing notes — Recent notes describing condition and needs
- Mobility and transfer status — Level of assistance and equipment required
- Equipment needs — Ventilator, trach, feeding tube, oxygen, specialty bed, Hoyer lift, etc.
- Respiratory needs — Vent settings, oxygen requirements, trach care, suctioning frequency
- Dialysis schedule — Modality, center, and days/times, if applicable
- Isolation status — Contact/droplet/airborne precautions, if applicable
- Behavioral / safety factors — Cognitive status, wandering, agitation, elopement risk
- Payer / funding information — Medicaid (COPES), private pay, LTC insurance, VA, PDN eligibility
- Requested discharge timeframe — Target date and urgency
Download the Referral Checklist (.txt) — printable for your team.
Secure Referral Submission
We know clinical referrals contain protected health information, and we treat that seriously.
- Call the direct line for PHI-containing referrals. For urgent cases and any referral that includes medical records, is the fastest and most secure path — our team will walk you through intake over the phone.
- Use the referral form for initial contact only. The web form is fine for basic intake details. It is not the channel for medical records.
- Please don't email PHI to our general inbox. Our general email is not a secure clinical channel, so we ask that you not send protected health information to it.
Medicaid and Complex Cases
We know that Medicaid patients with high-acuity needs are the hardest to place. Many facilities won't accept Medicaid at all. Those that do often can't handle complex medical needs.
We have solutions. Our network includes adult family homes that:
- Accept Medicaid as primary payment
- Have Private Duty Nursing (PDN) contracts through Medicaid
- Can accommodate high-acuity Medicaid patients that other facilities reject
If you're placing DSHS patients or Medicaid recipients with complex needs, we should talk. Some patients also qualify for a Community Integration (CI) add-on to the daily rate, which helps fund community-based activities at the AFH.
A Real Placement, Anonymized
Shared with the family's permission and with identifying details removed. Read the full story here: Case Study: How a Vent Patient Was Placed in 48 Hours.
A discharge planner had 48 hours to place a ventilator-dependent patient. The patient was medically stable but required 24/7 respiratory monitoring, and the family had spent two weeks calling homes with zero success — three skilled nursing facilities and two home care agencies had already said no.
We took the referral, verified the vent settings and nursing orders, confirmed PDN eligibility through the DSHS assessment on file, and shortlisted three pre-vetted PDN-contracted homes that had accepted vent patients before. The family toured two homes the next morning and chose one five minutes from their house. The discharge planner had a confirmed bed by the end of the second day.
That pace wasn't luck — it's what a pre-built network makes possible. It's also the exception, not the norm: this patient's funding was already confirmed and the homes had open beds. Most cases move in days, not necessarily 48 hours.
✨ Staff Resource
Quick Medicaid Rate Lookup for Discharge Planning
Before you call facilities, know what the DSHS daily rate will be. Our estimator gives you the estimated CARE classification and daily payment in under 3 minutes.
Rate Estimates
Related Placement Services
- High-Acuity Placement — complex cases needing PDN and skilled nursing
- Ventilator Care in Adult Family Homes — the complete family guide
- Tracheostomy Care Placement
- Bariatric Care Placement
- Dialysis Care Placement
- Wound Care Placement
- Pre-Medicaid Care
- Rapid Assessment
Build a Relationship
We're not just a one-time resource. We want to be your go-to partner for complex placements.
Let's talk. We're happy to meet with your team and learn about your caseload.
Have a Case Right Now?
Call the direct line and we'll start immediately. Or send the referral form and we'll follow up.
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Frequently Asked Questions
What does your service cost?
Nothing to you or the patient's family. Adult family homes pay us a placement fee only when a placement is successful. Our service is free for referrers and families. See how we're paid.
How quickly can you find placement?
We prioritize urgent referrals and commonly identify a shortlist of matching homes within 24–72 hours. Timing depends on patient acuity, home availability, and provider acceptance — we don't guarantee a specific timeline, and we'll keep you updated on progress.
What if the patient is on Medicaid?
We have homes in our network that accept Medicaid, including PDN-contracted homes for high-acuity Medicaid patients. Medicaid + complex needs is one of our specialties.
Do you cover my area?
We primarily serve King, Snohomish, Pierce, and Kitsap counties, concentrated in the greater Seattle metro area. Not sure? Call us and we'll tell you straight.
Is it secure to send you patient information?
For referrals that include protected health information, call our direct line and our team will walk you through intake — we ask that you not email PHI to our general inbox. The web form is for initial, non-PHI intake.
What happens if the placement doesn't work out?
We follow up at 30 and 90 days to catch issues early. If a placement fails, we'll help find an alternative. Our reputation depends on successful long-term placements.