Community Supports

Housing Transition Navigation Services

Includes a tenant housing screening, assessment; and an individualized housing support plan; housing search and options; assistance in securing housing; benefits advocacy and access to available resources to assist with subsidizing rent and to cover expenses; assistance with requests for reasonable accommodation; and landlord education and engagement.

Services must be identified as reasonable and necessary in the member’s individualized housing support plan with service duration lasting as long as necessary.

Housing Deposits

Help with security deposits, set-up fees/deposits for utilities, first month cost of utilities, first month’s and last month’s rent, and goods to establish a basic household.

Housing Deposits are available once in a member’s lifetime and can only be approved one additional time with documentation as to what conditions have changed to demonstrate why providing Housing Deposits would be more successful for a second time. Services must be identified as reasonable and necessary in the member’s individualized housing support plan and are available only when a member is unable to meet such expense. Members must also receive Housing Transition Navigation services in conjunction with this service.

Housing Tenancy and Sustaining Services

Help members identify and fix issues that may result in losing their housing, provide education and training on tenant and landlord responsibilities, help maintain a good relationship with landlord, resolve disputes with landlords or neighbors, connect to community resources to prevent eviction, access benefits, help with annual housing recertification process, update housing support and crisis plan, assist with lease compliance, health and safety inspections, other prevention and early intervention services, and independent living and life skills. 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

Services are available from the initiation of services through the time when the member’s housing support plan determines they are no longer needed. They are only available once in a member’s lifetime and can only be approved one additional time with documentation as to what conditions have changed to demonstrate why providing these services would be more successful on the second attempt. Services must be identified as reasonable and necessary in the member’s individualized housing support plan and are available only when a member is unable to successfully maintain longer-term housing without such assistance.

Medically Supportive Food/Meals/Medically Tailored Meals

Provides nutritional counseling, Medically Tailored Meals, and/or medically-supportive food for individuals with chronic diseases who were recently discharged or with a pending discharge from a hospital or nursing home f or who have the need for extensive care coordination support.

Members can receive up to two (2) meals per day or medically-supportive food for up to 12 weeks, or longer if medically necessary. Meals are not covered to respond solely to food insecurities.

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, and facilitates transition back into a home-like, community setting and/or to prevent skilled nursing admissions for members with an imminent need for nursing facility level of care.

Services include wrap-around services, medication oversight, therapeutic social and recreational programming in a home-like environment, meals, transportation, assistance with Activities of Daily Living (ADLs) and/or Instrumental ADLs (IADLs).

Members are directly responsible for paying their own living expenses.

Community Transition Services/Nursing Facility Transition to a Home

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

Covers non-recurring one-time expenses for individuals who are transitioning from a licensed facility to a living arrangement in a private residence that has been already secured. The member will be directly responsible for his or her own living expenses. Allowable expenses are those necessary to enable a person to establish a basic household that does not include room and board and include assessing of housing needs; communicating with landlord; coordinating the move; establishing process to retain housing; securing non-emergency, non-medical transportation; and identifying the need for and coordinating funding for environmental modifications if needed.

Services do not include monthly rental or mortgage expense, food, regular utility charges, and/or household appliances or items that are intended for purely diversionary/recreational purposes. Services must be necessary to ensure the health, welfare, and safety of the member, and without the support the member would be unable to move to the private residence and would then require continued or re-institutionalization.

Day Habilitation Programs

Provides services in or out of a person’s home to assist them in acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary to reside successfully in the community. Program services include, but are not limited to, training on:

• The use of public transportation;
• Personal skills development in conflict resolution;
• Community participation;
• Developing and maintaining interpersonal relationships;
• Obtaining and maintaining employment;
• Daily living skills (cooking, cleaning, shopping, money management); and
• Community resource awareness such as police, fire, or local services to support independence in the community.

Programs may include assistance with, but not limited to, the following:

• Selecting and moving into a home;
• Locating and choosing suitable housemates;
• Location household furnishings;
• Setting disputes with landlords;
• Managing personal financial affairs;
• Recruiting, screening, hiring, training, supervising, and dismissing personal attendants;
• Dealing with and responding appropriately to governmental agencies and personnel;
• Asserting civil and statutory rights through self-advocacy;
• Building and maintaining interpersonal relationships;
• Coordinating with SCFHP to link member to any Community Supports or Enhanced Care Management services;
• Submitting referrals to non-Community Supports housing resources if member does not meet Community Supports eligibility criteria;
• Assisting with income and benefits advocacy; and
• Coordinating with SCFHP to link member to health care, mental health services, and substance use disorder services based on individual need.

Program services are available for as long as necessary. Services can be provided continuously, or through intermittent meetings, in an individual or group setting.

Asthma Remediation

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

Examples of services or products include:

• Allergen-impermeable mattress and pillow dustcovers;
• High-efficiency particulate air (HEPA) filtered vacuums;
• Integrated Pest Management (IPM) services;
• De-humidifiers;
• Air filters;
• Other moisture-controlling interventions;
• Minor mold removal and remediation services;
• Ventilation improvements;
• Asthma-friendly cleaning products and supplies;
• Other interventions identified to be medically appropriate and cost effective.

Services are available in a home that is owned, rented, leased, or occupied by the member or their caregiver.

Individuals with poorly controlled asthma as determined by an emergency department visit, hospitalization, or two sick or 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 are physical adaptions to a home that are necessary to ensure the health, welfare, and safety of the member, or enable the member to function with greater independence in the home without support the member would require institutionalization.

Examples of services and products include:

• Ramps and grab bars to assist members in accessing the home;
• Doorway widening or members who require a wheelchair;
• Stair lifts;
• Making a bathroom and shower wheelchair accessible;
• Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies of a member;
• Installation and testing of Personal Emergency Response System (PERS) for members who are alone for significant parts of the day without a caregiver and who otherwise require routine supervision.

Services are available in a home that is owned, rented, leased, or occupied by the member or their caregiver. Services are available in a home that is owned, rented, leased, or occupied by the member or their caregiver. For a home that is not owned by the member, the member must provide written consent from the owner for physical adaptations to the home or for equipment that is physically installed in the home.

Eligibility includes:

• 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.

Modifications must be conducted in accordance with applicable state and local building codes. Services are payable up to a total lifetime maximum of $7,500 with the only exception to the maximum being if a member’s place of residence changes or if the member’s condition has changed to significantly those additional modifications are necessary to ensure the health, welfare, and safety of the member, or are necessary to enable the member to function with greater independence in the home and avoid institutionalization or hospitalization. Modifications may include finishing to return the home to a habitable condition, but do not include aesthetic embellishments. Modifications are limited to those that are of direct medical or remedial benefit to the member and exclude adaptations or improvements that are of general utility to the household. Adaptations that add to the total square footage of the home are excluded, except when necessary to complete an adaptation.

Personal Care and Homemaker Services

Services are provided to members who need assistance with Activities of Daily Living (ADLs), such as bathing, dressing, toileting, ambulation, or feeding. Personal Care Services can also include assistance with Instrumental ADLs such as meal preparation, grocery shopping, and money management. Includes services provided through the In-Home Support Services (IHSS) program, including house cleaning, meal preparation, laundry, grocery shopping, personal care services, accompaniment to medical appointments, and protective supervision for the mentally impaired.

Eligibility includes:

• Individuals at risk for hospitalization, or institutionalization in a nursing facility
• Individuals with functional deficits and no other adequate support system
• Individuals approved for IHSS, but have exhausted the approved number of hours or are in a waiting period to be approved for additional hours
• For members not eligible to receive IHSS, to help avoid a short-term stay in a skilled nursing facility (not to exceed 60 days)

Services cannot be utilized in lieu of referring to the IHSS program. Members must be referred to IHSS when they meet referral criteria. If a member receiving Personal Care and Homemaker Services has any change in their current condition, they must be referred to IHSS for reassessment and determination of additional hours. Members may continue to receive Personal Care and Homemaker Services during this reassessment waiting period.

Respite Services (Caregiver)

Short-term services provided to caregivers of members who require intermittent temporary supervision because of the absence or need for relief of those persons who normally care for and/or supervise them and are non-medical in nature. Services can include any of the following:

• Services provided by the hour on an episodic basis because of the absence of or need for relief for those persons normally providing the care to members.
• Services provided by the day/overnight on a short-term basis because of the absence of or need for relief for those persons normally providing the care to individuals.
• Services that attend to the member’s basic self-help needs and other activities of daily living, including interaction, socialization and continuation of usual daily routines that would ordinarily be performed by those persons who normally care for and/or supervise them.

Home Respite Services are provided to a member in his or her own home or another location being used as a home. Facility Respite Services are provided in an approved out-of-home location. Respite should be made available when it is useful and necessary to maintain a person in their own home and preempt caregiver burnout to avoid institutional services.

Eligibility includes:

• 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

In the home setting, these services, in combination with any direct care services the member is receiving, may not exceed 24 hours per day of care.

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, can access a safe, supportive environment to become sober.

Eligibility includes:

• 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

This service is covered for a duration of less than 24 hours.

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.

Eligibility includes:

• 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

Recuperative Care/Medical Respite is an allowable Community Supports if it is (1) necessary to achieve or maintain medical stability and prevent hospital admission or re-admission, which may require behavioral health interventions, (2) not more than 90 days in continuous duration, and (3) does not include funding for building modification or building rehabilitation.