Community Supports

What are Community Supports?

Community Supports (CS), previously known as In Lieu of Services or ILOS, are community-based services that address health-related social needs. Medi-Cal managed care health plans may offer these alternative services to their members to avoid hospital care, nursing facility care, visits to the emergency department or other costly services.

Which Community Supports are offered by SFHP?

• Medical Respite (Recuperative Care)
  Medical Respite is short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post-discharge treatment while obtaining access to primary care, behavioral health services, case management and other supportive social services, such as transportation, food, and housing.
• Sobering Center
  Sobering centers are alternative destinations 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. Sobering centers provide these individuals, primarily those who are homeless or those with unstable living situations, with a safe, supportive environment to become sober.
• Housing Transition Navigation Services (HTN)
  Housing Transition Navigation (HTN) services assists members who are homeless or at risk of experiencing homelessness with obtaining housing. HTN provides member support to address individual barriers to successful tenancy. Services include but are not limited to a housing assessment and plan, housing search and coordination of resources, advocacy, landlord education and engagement, and assistance with move-in. Contracted Providers are listed in SFHP’s provider directory.
• Medically Tailored Meals (MTM)
  Medically Tailored Meals are for members with chronic conditions. MTM helps members achieve their nutrition goals at critical times and helps them regain and maintain their health. Meals are individually tailored by a Registered Dietician and can be delivered to homes or picked up at an agreed upon location. Contracted Providers are listed in SFHP’s provider directory.
• Housing Deposits
  Housing deposits provide members assistance with housing security deposits, utilities set-up fees, first and last month’s rent, and first month of utilities. Members can also receive funding for medically necessary items like air conditioners, heaters, and hospital beds to ensure their new home is safe for moving in.
• Housing Tenancy Sustaining Services
  Housing Tenancy Sustaining Services provide members with support to maintain safe and stable tenancy once housing is secured, such as coordination with landlords to address issues, assistance with the annual housing recertification process, and linkage to community resources to prevent eviction.
• Home Modifications
  Home modifications help members receive physical modifications to their home to ensure their health and safety and allow them to function with greater independence. Home modifications can include ramps and grab-bars, doorway widening for members who use a wheelchair, stair lifts, or making bathrooms wheelchair accessible.
• Community Transition (NF Transition to Home)
  Community Transition supports members who are transitioning from a nursing facility to a private residence where they will be responsible for their own expenses, receive funding for set-up services such as security deposits, set-up fees for utilities, and health-related appliances, such as air conditioners, heaters, or hospital beds.
• Respite Services
  Respite Services are provided to caregivers of members who require intermittent temporary supervision. The services are provided on a short-term basis because of the absence or need for relief of those people who normally care for and/or supervise them and are non-medical in nature. This service is distinct from medical respite/recuperative care and is rest for the caregiver only. They aim to help members stay at home rather than needing institutional care, with options for both home-based and facility-based services.
• Nursing Facility Transition/Diversion to Assisted Living Facilities
  Nursing Facility Transition/Diversion services support individuals transitioning from nursing facilities to community settings, such as Assisted Living Facilities (ALF) or Residential Care Facilities for the Elderly (RCFE). These services include assessing housing needs, securing facility residences, and support with wrap around services at the ALF/RCFE once the member transitions. Overall, the goal is to promote independence and quality of life in a home-like environment while meeting the individual’s daily and ongoing care needs.

Eligibility Criteria

Medical Respite

Medical Respite is available for individuals who:

• Are at risk of going to a hospital or just getting released from a hospital.

OR

• Who live alone with no formal supports.

OR

• Who face housing insecurity or have housing that would jeopardize their health and safety without modification.

OR

• Who are homeless AND have at least 1 of the following:
  • Are getting Enhanced Care Management (ECM)
  • Have 1 or more serious chronic conditions
  • Have a serious mental illness
  • Have a substance use disorder
  • Are at risk for institutionalization
  • Are at risk for overdose or going to a hospital
• Are at risk of homelessness, have significant barriers to housing stability, and have one of the following:
  • Are receiving Enhanced Care Management
  • Have a disability.
  • Have 1 or more serious chronic condition or mental illness.
  • Have a substance use disorder.
  • Are at risk of going to a treatment facility.
  • Are at risk for overdose or going to a hospital because of a substance use disorder or Serious Emotional Disturbance.
  • Are age 16-26 years (inclusive) with a past of foster care, the criminal justice system, mental illness, serious emotional trauma, trafficking, or domestic violence.
  • Can transition out of inpatient facility care, skilled nursing care, or another health care facility and Recuperative Care is medically appropriate and cost-effective.

At risk of homelessness means that one of the following applies:

• Have a yearly income of less than 30% of the local median family income.
• No support system such as family, friends, or help from a church, and
  • Moved 2 or more times in the last 60 days.
  • Are living in some other person’s home.
  • Have been told to leave your place in the next 21 days.
  • Live in a hotel or motel that is not paid for by a program.
  • Live in a single-room occupancy (SRO) with 2 more people.
  • Live in a house that has more than 1.5 people per room.
  • Just left a facility such as a hospital, jail, foster care, etc.

Sobering Center

Sobering Center is available for:

• Individuals aged 18 and older who are intoxicated but conscious, cooperative, able to walk, nonviolent, free from any medical distress (including life threatening withdrawal symptoms or apparent underlying symptoms),

AND

• Who 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.

Housing Transition Navigation Services

Housing Transition Navigation Services are available for individuals who are in 1 of the following 3 groups:

1. Are prioritized for a permanent supportive housing unit or rental subsidy through San Francisco’s Coordinated Entry System.

2. Are experiencing homelessness and one of the following:

• Are receiving Enhanced Care Management.
• Have a disability.
• Have 1 or more serious chronic condition or mental illness.
• Have a substance use disorder.
• Are at risk of going to a treatment facility.
• Were just released from jail, a hospital, or other facility.

3. Are at risk of homelessness and have one of the following:

• Are receiving Enhanced Care Management.
• Have a disability.
• Have 1 or more serious chronic condition or mental illness.
• Have a substance use disorder.
• Are at risk of going to a treatment facility.
• Are age 16-26 years (inclusive) with a past of foster care, the criminal justice system, mental illness, serious emotional trauma, trafficking, or domestic violence.

At risk of homelessness means that one of the following applies:

• Have a yearly income of less than 30% of the local median family income.
• No support system such as family, friends, or help from a church, and
  • Moved 2 or more times in the last 60 days.
  • Are living in some other person’s home.
  • Have been told to leave your place in the next 21 days.
  • Live in a hotel or motel that is not paid for by a program.
  • Live in a single-room occupancy (SRO) with 2 more people.
  • Live in a house that has more than 1.5 people per room.
  • Just left a facility such as a hospital, jail, foster care, etc.

Medically Tailored Meals

Medically Tailored Meals are available for individuals who:

• Have a chronic condition such as, but not limited to:
  • Diabetes
  • Cardiovascular (heart) disorders
  • Human immunodeficiency virus (HIV)
  • Cancer
  • Mental or behavioral health disorders
  • High blood pressure (hypertension)

OR

• Have been released from a hospital or other facility or are at risk of hospitalization or nursing facility placement

OR

• Have extensive care coordination needs

Housing Deposits

Housing Deposits are available for individuals who are receiving Housing Transition Navigation Community Support Service and have one of the following:

1. Are prioritized for a permanent supportive housing unit or rental subsidy through San Francisco’s Coordinated Entry System.

OR

2. Are experiencing homelessness and one of the following:

• Are receiving Enhanced Care Management.
• Have a disability.
• Have 1 or more serious chronic condition or mental illness.
• Have a substance use disorder.
• Are at risk of going to a treatment facility.
• Were just released from jail, a hospital, or other facility.

Housing Tenancy and Sustaining Services

Housing Tenancy and Sustaining Services are available for individuals who:

• Received Housing Transition Navigation Services Community Support

OR

• Are prioritized for a permanent supportive housing unit or rental subsidy through San Francisco’s Coordinated Entry System.

OR

• Are experiencing homelessness and one of the following:
  • Are receiving Enhanced Care Management
  • Have a disability.
  • Have 1 or more serious chronic condition or mental illness.
  • Have a substance use disorder.
  • Are at risk of going to a treatment facility.
  • Were just released from jail, a hospital, or other facility.

OR

• Are at risk of homelessness and have one of the following:
  • Are receiving Enhanced Care Management.
  • Have a disability.
  • Have 1 or more serious chronic condition or mental illness.
  • Have a substance use disorder.
  • Are at risk of going to a treatment facility.
  • Are age 16-26 years (inclusive) with a past of foster care, the criminal justice system, mental illness, serious emotional trauma, trafficking, or domestic violence.

At risk of homelessness means that you have one of the following:

• Have a yearly income of less than 30% of the local median family income.
• No support system such as family, friends, or help from a church, and
  • Moved 2 or more times in the last 60 days.
  • Are living in some other person’s home.
  • Have been told to leave your place in the next 21 days.
  • Live in a hotel or motel that is not paid for by a program.
  • Live in a single-room occupancy (SRO) with 2 more people.
  • Live in a house that has more than 1.5 people per room.
  • Just left a facility such as a hospital, jail, foster care, etc.

Home Modifications (Environmental Accessibility Adaptations)

Home Modifications (Environmental Accessibility Adaptations) are available for individuals at risk for institutionalization in a nursing facility

Community Transition Services / Nursing Facility Transition to The Community

Community Transition Services / Nursing Facility Transition to The Community services are available for individuals who meet all the below criteria:

• Are currently receiving a medically necessary level of Care (LOC) services and choosing to transition from a nursing facility or medical respite
• Lived 60+ days in a nursing home or medical respite setting
• Are interested in moving back to the community and can do so safely

Respite Services

• Individuals in the community reliant on caregivers due to limitations in Activities of Daily Living (ADLs)
• Need caregiver relief to prevent institutional placement
• Includes subsets like children under Pediatrics Palliative Care Waiver, foster care beneficiaries, California Children’s Services or GHPP enrollees, and those with Complex Care Needs

Nursing Facility Transition/Diversion to Assisted Living Facilities

For Nursing Facility Transition:

• Resided 60+ days in a nursing facility or hospital
• Willing to live in assisted living as an alternative
• Able to reside safely with appropriate supports

For Nursing Facility Diversion:

• Interested in remaining in the community
• Willing and able to live safely in assisted living with support
• Currently receiving medically necessary nursing facility level of care or meet criteria for it, choosing assisted living instead

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

Provider contacts SFHP

For information on referrals, please call the Care Management intake line at 1(415) 615-4501 or SFHP Customer Service at 1(415) 547-7800.

Providers can also submit a Community Supports Referral Form to the Care Management Intake Team. Our referral forms are below, and submission instructions are included on the forms.

• Housing Transition Navigation (HTN) Referral Form
• Medically Tailored Meals/Groceries (MTM) Referral Form
• Housing Deposits Referral Form
• Housing Tenancy Sustaining Services Referral Form
• Home Modifications Referral Form
• Community Transitions (Nursing Facility Transition to Home) Referral Form
• Respite Services Referral Form
• Nursing Facility Transition/Diversion to Assisted Living Facilities Referral Form
• No referral is required to access Sobering Center Services
• Medical Respite referrals are made directly by the hospital to the Medical Respite facility. The contact information for hospitals to make referrals to Medical Respite is 1(415) 734-4216 or respite-referrals@sfdph.org.

A member asks to join

Members can contact SFHP Customer Service at 1(415) 547-7800 to verify eligibility and pursue applicable next steps. Enhanced Care Management members can request a referral from their care managers.

Can members receive multiple Community Supports?

Yes. Many members qualify for one or several Community Supports. Community Supports referrals are encouraged for ECM recipients as they help keep members safe, supported, and reduce inpatient stays.