Community Supports (CS)

Asthma Remediation consists of supplies and/or physical modifications to a member’s home environment that are necessary to:

• Ensure the health, welfare, and safety of the member,
  or
• Enable the member to function in the home with a reduced likelihood of experiencing acute asthma episodes.

Eligibility Criteria

• Completion of an in-home environmental trigger assessment within the last 12 months through the APS benefit.

Units per CS service option

Community or Home Transition Services is formerly known as Community Transitions/Nursing Facility to Home.

Provides coordination of services to qualified members. Coverage includes (but is not limited to) nonrecurring home setup expenses for eligible members who are able to transition from a licensed facility into the community. This helps prevent further institutionalization based on each members’ individual needs.

Eligibility Criteria

• Currently receiving medically necessary nursing facility Level of Care (LOC) services and in lieu of remaining in the nursing facility or Recuperative Care setting are choosing to transition home and continue to receive medically necessary nursing facility LOC services;
  and
• Have lived 60+ days in a nursing home and/or Recuperative Care setting;
  and
• Are interested in moving back to the community;
  and
• Are able to reside safely in the community with appropriate and cost-effective supports and services.

Units per CS service option

Housing Transition Navigation Services help members move into stable housing by addressing barriers and connecting them to resources. Services include:

• Housing Assessment: Identify member preferences, housing needs, and barriers to successful tenancy.
• Housing Support Plan: Develop a plan based on the assessment, following Section V.B.3 requirements.
• Housing Search Assistance: Support members in locating housing and presenting available options.
• Resource Coordination: Identify and secure housing-related resources such as Transitional Rent, HUD Housing Choice Vouchers, and other state/local programs.
• Fair Housing Education: Provide education on Fair Housing and anti-discrimination practices, including assistance with reasonable accommodation requests.

Eligibility Criteria

Members may qualify for Housing Transition Navigation Services if they meet one of the following:

1. Social + Clinical Risk Factors
   • Social Risk Factor: Experiencing or at risk of homelessness
     and
   • Clinical Risk Factor: One or more of the following:
     • Meets access criteria for Medi-Cal Specialty Mental Health Services (SMHS).
     • Meets access criteria for Drug Medi-Cal (DMC) or DMC-ODS.
     • Has one or more serious chronic physical health conditions.
     • Has one or more physical, intellectual, or developmental disabilities.
     • Is pregnant (up to 12 months postpartum).
2. Transitional Rent
   • Member is eligible for Transitional Rent (automatic eligibility for HTNS).
3. Coordinated Entry Prioritization
   • Member is prioritized for permanent supportive housing or rental subsidy through the local Coordinated Entry System or similar program for highly vulnerable individuals (e.g., with disabilities, chronic conditions, serious mental illness, substance use disorder, or exiting incarceration).

Additional Information

• All services must be documented in the member’s housing support plan.
• For full policy details, refer to DHCS Community Supports Policy Guide (Volume 1 and Volume 2).

Provides physical adaptations to members’ homes that are necessary to avoid institutionalization and increase independence or ensure health, welfare and safety.

Eligibility Criteria

• Received PT/OT evaluation supporting medical necessity. 
• Has PCP or other health professional Rx/order for medically necessary equipment or service.

Units per CS service option

Assistance with one-time costs and services needed to establish a basic household. Supports are based on an individual assessment of needs and must be documented in the member’s housing support plan. Members may only require a subset of these services.

Covered Services May Include:

• Security deposits required to obtain a lease.
• Health and safety services such as:
  • Pest eradication.
  • One-time cleaning prior to occupancy.
  • Minor repairs to meet HUD Housing Choice Voucher or other habitability standards (when costs are not the landlord’s responsibility).
• Application fees for lease applications.

Eligibility Criteria

1. Social + Clinical Risk Factors
   • Social Risk Factor: Experiencing or at risk of homelessness
     and
   • Clinical Risk Factor: One or more of the following:
     • Meets access criteria for Medi-Cal Specialty Mental Health Services (SMHS).
     • Meets access criteria for Drug Medi-Cal (DMC) or DMC-ODS.
     • Has one or more serious chronic physical health conditions.
     • Has one or more physical, intellectual, or developmental disabilities.
     • Is pregnant (up to 12 months postpartum).
2. Transitional Rent: Member is eligible for Transitional Rent (automatic eligibility for Housing Deposits).
3. Coordinated Entry Prioritization: Member is prioritized for permanent supportive housing or rental subsidy through the local Coordinated Entry System or similar program for highly vulnerable individuals (e.g., with disabilities, chronic conditions, serious mental illness, substance use disorder, or exiting incarceration).

Restrictions

• Housing Deposits are available once per demonstration period; a second approval requires documentation of changed circumstances.
• Members must have a housing support plan; all services and goods must be identified as reasonable and necessary in the plan.
• Receipt of Housing Transition Navigation Services is not required to receive Housing Deposits.

Units per CS service option

Provides up to six months of rental assistance in interim or permanent housing settings for members who are experiencing or at risk of homelessness, have specified clinical risk factors, and have recently undergone a critical life transition (e.g., exiting institutional or carceral settings, foster care) or meet other eligibility criteria outlined in program guidance.

Eligibility Criteria

Currently, only select members with Behavioral Health Population Focus are eligible for this service:

1. Clinical Risk Factor Requirement: One or more of the following:
   Required for Behavioral Health Population of Focus: Access criteria for Medi-Cal SMHS, DMC or DMC-ODS.
   • Serious chronic physical health conditions.
   • Physical, intellectual, or developmental disabilities.
   • Pregnant (up to 12 months postpartum).
2. Required for Behavioral Health Population of Focus: Social Risk Factor Requirement: Experiencing or at risk of homelessness.
3. Required for Behavioral Health Population of Focus: Transitioning Population Requirement: Must be included in one of the following:
   • Transitioning out of institutional/congregate residential setting (hospital, SUD/MH facility, nursing facility).
   • Transitioning from incarceration (prison, jail, youth correctional facility).
   • Transitioning from foster care (eligible until 26th birthday if transitioned after 18th birthday).
   • Experiencing unsheltered homelessness.
   • Eligible for Full-Service Partnership (FSP) programs.

Additional Information

• Transitional Rent must be authorized within six months of the transition event.
• Benefit is available for six months from authorization without redetermination.

Units per CS service option

Available a single duration in a lifetime.

Provides tenancy and sustaining services including (but not limited to) advocacy, coordination, resource referrals, life-skills coaching and health/safety visits with a goal of maintaining stable tenancy once housing is secured based on the member’s individualized needs.

Eligibility Criteria

• Received Housing Transitions Navigation Services.
  or
• Prioritized for permanent supportive housing or rental subsidy resource through San Mateo CES or similar County system/resource.
  or
• Are experiencing or at risk of homelessness, including those at risk of losing housing.

Units per CS service option

Provides medically tailored home-delivered meals for members with chronic conditions to help achieve their nutrition goals at critical times and help them regain and maintain their health. Starting July 1st, 2025 members will be required to have one nutritional assessment conducted by the Community Supports Service Provider in order to receive Medically Tailored Meals.

Eligibility Criteria

To qualify for Medically Tailored Meals, patient must meet both of the following requirements:

• Have a nutrition-sensitive condition (such as diabetes, heart disease, kidney disease, or other conditions where diet impacts health).
• Complete a required nutrition assessment conducted by the contracted Meals Provider

Units per CS service option

Assisted Living Facility Transitions is formerly known as Nursing Facility Transition / Diversion to Assisted Living Facilities.

Provides coordination of services to facilitate nursing facility 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 (LOC). Members have the choice of residing in an ALF as an alternative to long-term placement in a nursing facility when they meet eligibility requirements.

Criteria for SNF transition

• Residing in SNF for more than 60 days,
  and
• Willing and able to reside safely in an Assisted Living Facility (ALF) or Residential Care Facility for the Elderly (RCFE) in lieu of a SNF with appropriate supports in place.

Criteria for SNF diversion

• Wants to remain in the community;
  and
• Meets minimum criteria for SNF level of care, and, in lieu of going into a facility, choose to remain in the community and continue to receive medically necessary nursing facility LOC services at an Assisted Living Facility;
  and
• Willing and able to reside safely in an ALF/RCFE in lieu of SNF with appropriate supports in place.

Units per CS service option

Provides assistance to members who could not otherwise remain in their homes. Helps with activities of daily living (ADLs) such as ambulation, bathing, dressing, toileting, grocery shopping, meal preparation, feeding and money management. Includes services provided through in-home supportive services (IHSS).

Eligibility Criteria

• Approved for IHSS but needs additional hours. IHSS benefits are exhausted.
• Currently in IHSS waiting period. Includes services prior to and through the IHSS application date for an IHSS-referred member during IHSS waiting period.
• If not eligible for IHSS, to help avoid a short-term skilled nursing facility stay (not to exceed 60 days).
• Has functional deficits and no other adequate support system.

Units per CS service option

Provides non-medical, short-term services to members due to the absence of or need to relieve their caregivers to prevent burnout.

Eligibility Criteria

• Lives in the community and is compromised in their ADLs and are therefore dependent upon a qualified caregiver who provides most of their support.
• Requires caregiver relief to avoid institutional placement.

Units per CS service option