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Community Supports

Community Supports is one element of California Advancing and Innovating Medi-Cal (CalAIM), the Department of Health Care Services’ multi-year process to transform Medi-Cal. As an extension of the Whole Person Care (WPC) pilot and the Health Homes Program (HHP), Community Supports contributes to an integrated approach to coordinating medical care, behavioral health, and social services to improve beneficiary health outcomes.

The Department of Health Care Services (DHCS) defines Community Supports as medically-appropriate and cost-effective substitutes or settings for more costly state-paid health care services. Community Supports are not Medi-Cal benefits, but supplemental services paid by Santa Clara Family Health Plan (SCFHP) that focus on addressing combined medical and social determinants of health needs to avoid higher levels of care and are typically delivered by a different provider or in a different setting than traditional Medi-Cal benefits.

As of July 1, 2022, SCFHP offers eight of the 14 Community Supports approved by DHCS. SCFHP plans to offer the additional six Community Supports over the next year. To be eligible, members must meet eligibility criteria as defined by DHCS and it varies by Community Supports.

Implementation Timeline:

Effective January 1, 2022:

  • Housing Transition Navigation Services
  • Housing Deposits
  • Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities
  • Community Transition Services/Nursing Facility Transition to a Home
  • Medically Supportive Food/Meals/Medically Tailored Meals

Effective July 1, 2022:

  • Housing Tenancy and Sustaining Services
  • Recuperative Care (Medical Respite)
  • Sobering Center

Starting January 1, 2023:

  • Respite Services (Caregiver)
  • Environmental Accessibility Adaptations (Home Modifications)
  • Asthma Remediation
  • Personal Care and Homemaker Services

Starting July 1, 2023:

  • Short-term Post-Hospitalization Housing
  • Day Habilitation Programs

SCFHP Community Supports Services:

Housing Transition Navigation Services

Includes a housing assessment and plan, help with the housing search, resources and accommodations, and assistance with move-in and housing retention.

Housing Deposits

Help with first/last month’s rent, health and safety based on move-in requirements.

Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities

Provides help that allows members to live in the community and/or avoid institutionalization when possible.

Community Supports providers will help facilitate transition back into a home-like, community setting and/or prevent skilled nursing admissions for members with an imminent need for nursing facility level of care.

Community Transition Services/Nursing Facility Transition to a Home

Provides help that allows members to live in the community and avoid further institutionalization.

Covers nonrecurring setup expenses for individuals who are transitioning from a licensed facility to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses.

Medically Supportive Food/Meals/Medically Tailored Meals

Provides meals that help members achieve their nutrition goals at a critical time to regain and maintain their health. Services include Medically-Tailored Meals or groceries.

Housing Tenancy and Sustaining Services

Help members maintain safe and stable tenancy once housing is secured. This does not include the provision of room and board and is only available for up to 24 months.

  • Member must have secured housing
  • Previously experiencing homeless or at risk of becoming homeless

Sobering Center

An alternative destination for individuals who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Members, primarily those who are homeless or those with unstable living situations, access this safe, supportive environment to become sober.

  • 18 + years
  • Intoxicated
  • Conscious
  • Cooperative
  • Able to walk
  • Nonviolent
  • Free from any medical distress (including life threatening withdrawal symptoms or apparent underlying symptoms)
  • Would otherwise be transported to the emergency department or a jail or who presented at an emergency department and are appropriate to be diverted to a Sobering Center

Medical Respite/Recuperative Care

Short-term residential care for members who no longer require hospitalization, but still need to heal from an injury or illness and whose condition would be exacerbated by an unstable living environment.

  • Individuals who are at risk of hospitalization or are post-hospitalization, and unhoused
  • Individuals who live alone with no formal or who face housing insecurity or have housing that would jeopardize their health and safety without modification

How do eligible Medi-Cal members get Community Supports Services?

  • A provider submits a referral form for a member. Providers can submit a referral form to SCFHP for Community Supports through the Provider Portal. They can also download a referral form and send the complete form to SCFHP.
  • A member asks to join. Individuals can contact SCFHP Customer Service at
    1-800-260-2055 (TTY: 711) and ask if they qualify for Community Supports. If the member is currently enrolled in Enhanced Care Management (ECM), they may also request a referral from their Care Manager.