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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.

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

Asthma Remediation

Services completed to provide physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization.

  • Individuals with poorly controlled asthma (as determined by an emergency department visit, hospitalization, being too sick for urgent care visits in the past 12 months, or a score of 19 or lower on the Asthma Control Test) for whom a licensed health care provider has documented that the service will likely avoid asthma-related hospitalizations, emergency department visits, or other high-cost services

Environmental Accessibility Adaptations (Home Modifications)

Services completed to provide physical adaptions to a home that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function with greater independence in the home.

  • Individuals at risk for institutionalization in a nursing facility
  • Documentation from the primary care provider, current primary care physician or other health professional specifying the requested equipment or service
  • A physical or occupational therapy evaluation and report
  • Determination that requested equipment or services are needed based on a conducted home visit

Personal Care and Homemaker Services

Supports for individuals who need assistance with daily activities, such as bathing, getting dressed, personal hygiene, cooking, and eating.

  • Individuals at risk for hospitalization, or institutionalization in a nursing facility
  • Individuals with functional deficits and no other adequate support system
  • Individuals approved for In-Home Supportive Services.
  • For members not eligible to receive In-Home Supportive Services, to help avoid a short-term stay in a skilled nursing facility (not to exceed 60 days)

Respite Services (Caregiver)

Short-term services provided to caregivers of those who require occasional temporary supervision to give relief to the caregiver.

  • Individuals who live in the community and are compromised in their Activities of Daily Living (ADLs) and are therefore dependent upon a qualified caregiver who provides most of their support, and who require caregiver relief to avoid institutional placement
  • Children who previously were covered for Respite Services under the Pediatrics Palliative Care Waiver and foster care program beneficiaries
  • Members enrolled in either California Children’s Services or the Genetically Handicapped Persons Program (GHPP)
  • Members with Complex Care Needs

Starting July 1, 2023:

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

How do eligible SCFHP 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 ask SCFHP Customer Service to join. Individuals can contact us to ask if they qualify for Community Supports.
  • A member can ask their Care Manager or Case Manager to join. If the member is enrolled in Medi-Cal’s Enhanced Care Management (ECM), they can contact their ECM Care Manager for information on Community Supports. SCFHP DualConnect members can contact their Case Manager to see if they can include Community Supports to their individual care plan.

Santa Clara Family Health Plan DualConnect is an HMO D-SNP with a Medicare and Medi-Cal contract. Enrollment in DualConnect depends on contract renewal.

Last updated 12/27/2022