CalAIM Programs

Eligibility Criteria 

1. Adults (whether or not they have dependent children/youth living with them) who:
1. Are experiencing homelessness, defined as meeting one or more of the following conditions:
   1. Lacking a fixed, regular, and adequate nighttime residence;
   2. Having a primary residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground;
   3. Living in a supervised publicly or privately operated shelter, designed to provide temporary living arrangements (including hotels and motels paid for by federal, state, or local government programs for low income individuals or by charitable organizations, congregate shelters, and transitional housing);
   4. Exiting an institution into homelessness (regardless of length of stay in the institution);
   5. Will imminently lose housing in next 30 days;
   6. Fleeing domestic violence, dating violence, sexual assault, stalking, and other dangerous, traumatic, or life-threatening conditions relating to such violence;
      AND
2. Have at least one complex physical, behavioral, or developmental need, with inability to successfully self-manage, for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high- cost services.

Eligibility Criteria 

1. Children, Youth, and Families with members under 21 years of age who:
   1. Are experiencing homelessness, as defined above in (a) under the modified HHS 42 CFR Section 11302 “Homeless” definition;
      OR
   2. (2) Sharing the housing of other persons (i.e., couch surfing) due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; or abandoned in hospitals (in hospital without a safe place to be discharged 15 to), as modified from the 45 CFR 11434a McKinney-Vento Homeless Assistance Act definition of “at risk of homelessness”.

Eligibility Criteria 

1. Adults who meet one or more of the following conditions:
   1. Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence;
   2. Three or more unplanned hospital and/or short-term skilled nursing facility (SNF) stays in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

       

2. Children and youth who meet one or more of the following conditions:
   1. Three or more ED visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence;
   2. Two or more unplanned hospital and/or short-term SNF stays in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

Eligibility Criteria 

1. Adults with Serious Mental Health and/or SUD Needs who:
   1. Meet the eligibility criteria for participation in, or obtaining services through:
      1. SMHS delivered by MHPs;
      2. The Drug Medi-Cal Organization Delivery System (DMC-ODS) OR the Drug Medi- Cal (DMC) program;

         AND

   2. Are experiencing at least one complex social factor influencing their health (e.g., lack of access to food, lack of access to stable housing, inability to work or engage in the community, high measure (four or more) of ACEs based on screening, former foster youth, history of recent contacts with law enforcement related to mental health and/or substance use symptoms;

      AND

   3. Meet one or more of the following criteria
      1. Are at high risk for institutionalization, overdose, and/or suicide;
      2. Use crisis services, EDs, urgent care, or inpatient stays as the primary source of care;
      3. experienced two or more ED visits or two or more hospitalizations due to serious mental health or SUD in the past 12 months;

          

2. Children and youth who:
   1. Meet the eligibility criteria for participation in, or obtaining services through one or more of:
      1. SMHS delivered by MHPs;
      2. The DMC-ODS OR the DMC program.

Eligibility Criteria 

1. Adults who:
   1. Are transitioning from a correctional facility (e.g., prison, jail, or youth correctional facility) or transitioned from correctional facility within the past 12 months;

      AND

   2. Have at least one of the following conditions:
      1. Mental illness
      2. SUD
      3. Chronic Condition/Significant Non-Chronic Clinical Condition
      4. Intellectual or Developmental Disability (I/DD)
      5. Traumatic Brain Injury (TBI)
      6. HIV/AIDS
      7. Pregnant or Postpartum
         
         
2. Children and Youth Transitioning from a Youth Correctional Facility Children and youth under 21 or former foster youth between 18 and 26 who are transitioning from a youth correctional facility or adult jail/prison or transitioned from being in a youth correctional facility or adult jail/prison within the past 12 months.

Eligibility Criteria 

1. Adults who:
   1. Are living in the community who meet the SNF Level of Care (LOC) criteria; OR who require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury;

      AND

   2. Are actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with activities of daily living (ADLs), communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision- making, poor or inadequate caregiving which may appear as a lack of safety monitoring);
      AND
   3.  Are able to reside continuously in the community with wraparound supports (i.e., some individuals may not be eligible because they have high-acuity needs or conditions that are not suitable for home-based care due to safety or other concerns).

Eligibility Criteria 

1. Adult nursing facility residents who:
   1. Are interested in moving out of the institution; AND
   2. Are likely candidates to do so successfully; AND
   3. Are able to reside continuously in the community.

Eligibility Criteria 

1. Children and youth who:
   1. Are enrolled in CCS OR CCS WCM;
      AND
   2. Are experiencing at least one complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of ACEs screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health and/or substance use symptoms.

Eligibility Criteria 

1. Children and youth who meet one or more of the following conditions:
   1. Are under age 21 and are currently receiving foster care in California;

       

2. Are under age 21 and previously received foster care in California or another state within the last 12 months;
   1.  Have aged out of foster care up to age 26 (having been in foster care on their 18th birthday or later) in California or another state;
   2. Are under age 18 and are eligible for and/or in California’s Adoption Assistance Program;
   3. Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months.

Eligibility Criteria 

1. Adults and youth who:
   1. Are pregnant OR are postpartum (through 12 months period);
      AND
   2. Are subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality.

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 persons 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. 

Respite Services can include any of the following: 

1. 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 individuals. 
2. 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.
3. Services that attend to the Member’s basic self-help needs and other activities of daily living (ADL), 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 the Member in his or her own home or another location being used as the 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 to pre-empt caregiver burnout to avoid institutional services for which the Medi-Cal MCP is responsible.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Respite Services Community Support Referral form.

 

Assisted Living Facility Transitions (formerly known as “Nursing Facility Transition/Diversion to Assisted Living Facilities such as Residential Care Facilities for the Elderly and Adult Residential Facilities”) is designed to assist individuals with living in the community and avoid institutionalization, whenever possible. The goal of the service is to facilitate nursing facility transition back into a home-like, community setting, and/or to prevent nursing facility admissions for Members living in the community. This Community Support is intended for Members with an imminent need for nursing facility level of care (LOC) and is intended to provide a choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility. 

For the purposes of this service definition, the term assisted living facility (ALF) includes a Residential Care Facility for the Elderly (RCFE), or an Adult Residential Care Facility (ARF). This service includes two components, as follows: 

Time-limited transition services and expenses to enable a person to establish a residence in an ALF. Transition services end once the Member establishes residency in the ALF. The transitional period will vary in length and services provided based on a Member’s unique circumstances. Allowable expenses are those necessary to enable a person to establish ALF residence (except room and board), including, but not limited to: 

1. Assessing the Member’s housing needs and presenting options. 
2. Assessing the service needs of the Member to determine if the Member needs enhanced onsite services at the ALF, so the Member can be safely and stably housed. 
3. Assisting in securing an ALF residence, including the completion of facility applications, and securing required documentation (e.g., Social Security card, birth certificate, prior rental history). 
4. Moving expenses to support a Member’s transition, such as movers/moving supplies and necessary private/personal articles to establish an ALF residence. 
5. Communicating with facility administration and coordinating the move. 
6. Establishing procedures and contacts to retain housing at the ALF. 

Ongoing assisted living services are provided to Members on an ongoing basis after they transition into the ALF. Members can receive these services indefinitely, as long as the Member can maintain residency in the ALF. These services include: 

1. Assistance with Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs) 
2. Meal preparation c. Transportation d. Medication administration and oversight 
3. Companion services 
4. Therapeutic social and recreational programming provided in a home-like environment 
5. 24-hour direct care staff onsite at the ALF to meet unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety, and security 
6. Care coordination services to screen for eligibility and support enrollment of Members in Enhanced Care Management (ECM) and other Community Supports

MCPs may not limit their offering of this service to only component 1 (time-limited transition services and expenses) or component 2 (ongoing assisted living services) and must offer both to the extent that they are appropriate for the Member. However, individual Members may require only one or only the other component (e.g., Members already in the ALF will require only component 2 since they are not transitioning; Members enrolled in a waiver program that covers similar wraparound services may require only component 1).

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Adult ECM Referral Form form. An ECM LCM will assist with coordinating this Community Support.

Community or Home Transition Services (formerly known as “Community Transition Services/Nursing Facility Transition to a Home”) helps individuals to live in the community and avoid further institutionalization in a nursing facility. 

Community or Home Transition Services support Members in transitioning from a licensed nursing facility to a living arrangement in a private residence or public subsidized housing where the Member is responsible for identifying funding for their living expenses. This service also covers set-up expenses necessary for a Member to establish a basic household. 

This service includes two components, as follows:

1. Time-limited transition services and expenses to enable a Member to transition from a licensed facility to a private residence or public subsidized housing. Each transitional period will vary in length and services provided based on a Member’s unique circumstances. Includes services such as:

a. Assessing the Member’s housing needs and presenting options. 
b. Assisting in searching for and securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history).
c. Communicating with the landlord (if applicable) and coordinating the move. 
d. Establishing procedures and contacts to retain housing. 
e. Identifying, coordinating, securing, or funding non-emergency, non-medical transportation to assist Members’ mobility to ensure reasonable accommodations and access to housing options prior to transition and on move-in day.
f. Identifying the need for and coordinating funding for environmental modifications to install necessary accommodations for accessibility.

2. Non-recurring set-up expenses are those necessary to enable a Member to establish a basic household that does not constitute room and board and include: 

a. Security deposits required to obtain a lease on an apartment or home. Security deposits should be in alignment with AB-12, 25 enacted in 2024; 
b. Set-up fees for utilities or service access and up to six months’ payment in utility arrears, as necessary to secure the unit; 
c. Services necessary for the individual’s health and safety, such as pest eradication and one-time cleaning prior to occupancy, and necessary repairs to meet Housing Choice Voucher program quality standards where those costs are not the responsibility of the landlord under applicable law;
d. Air conditioner or heater; 
e. Adaptive aids designed to preserve an individual’s health and safety in the home, such as hospital beds, Hoyer lifts, bedside commode, shower chair, traction, or non-skid strips, etc., that are necessary to ensure access and safety for the individual upon move-in to the home, when they are not otherwise available to the Member under Medi-Cal (e.g., State Plan, HCBS waiver, etc.).  

MCPs may not limit their offering of this service to only component 1 or component 2 and must offer both to the extent that they are applicable to each Member.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Community or Home Transition Services Community Support Referral form.

Personal Care Services and Homemaker Services (PCHS) can be provided for individuals 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 Activities of Daily Living (IADLs) such as meal preparation, grocery shopping, and money management. 

Includes services as similarly provided by the In-Home Supportive Services (IHSS) program, including house cleaning, meal preparation, laundry, grocery shopping, personal care services (such as bowel and bladder care, bathing, grooming, and paramedical services), accompaniment to medical appointments, and protective supervision for the mentally impaired. 

PCHS aid individuals who could otherwise not remain in their homes. 

The PCHS Community Support can be utilized: 

• During the IHSS application process, including during any waiting period after a referral has been made. PCHS may be authorized prior to, and up until, IHSS services are in place.
• In addition to any approved county IHSS hours when additional support is required, including when IHSS benefits are exhausted. 
• For Members who are ineligible for IHSS, PCHS can be put in place to help prevent a short-term stay in a skilled nursing facility (not to exceed 60 days). In order to receive short term PCHS, Members are not required to apply for IHSS, but the authorization request should include information about the need for short term stay in a skilled nursing facility in the absence of PCHS being available.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Personal Care and Homemaker Services Community Support Referral form.

Environmental Accessibility Adaptations (EAAs also known as Home Modifications) are physical adaptations 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: without which the Member would require institutionalization. 

Examples of environmental accessibility adaptions include:

• Ramps and grab bars to assist Members in accessing the home 
• Doorway widening for Members who require a wheelchair 
• Stair lifts 
• Making a bathroom and shower wheelchair accessible (e.g., constructing a roll-in shower)
• Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies of the Member 
• Installation and testing of a 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 (including monthly service costs, as needed) 

 The services are available in a home that is owned, rented, leased, or occupied by the Member. 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 (e.g., grab bars, chair lifts, etc.). 

When authorizing environmental accessibility adaptations as a Community Support, the MCP must receive and document an order from the Member’s current primary care physician or other health professional specifying the requested equipment or service as well as documentation from the provider of the equipment or service describing how the equipment or service meets the medical needs of the Member, including any supporting documentation describing the efficacy of the equipment where appropriate. Brochures will suffice to show the purpose and efficacy of the equipment; however, a brief written evaluation specific to the Member describing how and why the equipment or service meets the needs of the Member will still be necessary.

1. A physical or occupational therapy evaluation and report to evaluate the medical necessity of the requested equipment or service unless the MCP determines it is appropriate to approve without an evaluation. This should typically come from an entity with no connection to the provider of the requested equipment or service. The physical or occupational therapy evaluation and report should contain at least the following: 

A. An evaluation of the Member and the current equipment needs specific to the Member, describing how/why the current equipment does not meet the needs of the Member; 

B. An evaluation of the requested equipment or service that includes a description of how/why it is necessary for the Member and reduces the risk of institutionalization. This should also include information on the ability of the Member and/or the primary caregiver to learn about and appropriately use any requested item, and 

C. A description of similar equipment used either currently or in the past that has demonstrated to be inadequate for the Member and a description of the inadequacy. 

2. If possible, a minimum of two bids from appropriate providers of the requested service, which itemize the services, cost, labor, and applicable warranties; and 
3. That a home visit has been conducted to determine the suitability of any requested equipment or service. 

The assessment and authorization for EAAs must take place within a 90-day time frame beginning with the request for the EAA, unless more time is required to receive documentation of homeowner consent, or the individual receiving the service requests a longer time frame.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Environmental Accessibility Adaptations Community Support Referral form.

Medically Tailored Meals (MTM) and Medically Supportive Food (MSF) services are designed to address individuals’ chronic or other serious conditions that are nutritionsensitive, leading to improved health outcomes and reduced unnecessary costs. 

Medically Tailored Meals and Groceries: MTMs and Medically Tailored Groceries (MTGs) are covered by this service, defined as follows: a. MTMs: 

a. Meals that adhere to established, evidence-based nutrition guidelines for specific nutrition-sensitive health conditions. 
b. MTG: Preselected whole food items that adhere to established, evidence-based nutrition guidelines for specific nutrition-sensitive health conditions. 

The provision of MTMs/MTGs must include an individual assessment of the Member’s nutrition-sensitive condition and nutritional needs conducted or supervised by Registered Dietitian Nutritionist (RDN) to inform the development of a nutritional plan and connection to the appropriate MTM or MTG services. 

The design of each of the MTM/MTG services (e.g., uncontrolled diabetes meal plan, congestive heart failure grocery plan) must be tailored by an RDN or other appropriate clinician to ensure the food provided adheres to established, evidence-based nutrition guidelines to prevent, manage, or reverse the targeted nutrition-sensitive health condition(s). 

The MTM and/or MTG assistance provided (singularly or in a combination of meals and groceries) must meet at least two-thirds of the daily nutrient and energy needs of an average individual, as estimated by the RDN/clinician overseeing the design of the MTM/MTG services. “Medically tailored” interventions must be provided in specified quantities to constitute the majority of the Member’s diet over the course of the intervention to have the intended impact on health outcomes. MTM/MTG must not contain ultra-processed foods nor foods with excessive sugar or salt.

Medically Supportive Food (MSF): MSFs are packages of foods that adhere to national nutrition guidelines to prevent, manage, or reverse nutrition-sensitive conditions of referred Members. Unlike MTM or MTG, MSF is intended to supplement, rather than replace, all or most of the Member’s diet. The design or selection of foods or food options in MSF services must be overseen and signed off on by an RDN or another appropriate clinician. RDNs do not need to oversee the assembly of each grocery box or produce prescription, but, for example, should provide or review the nutrition parameters of the types of foods to be included or approved for the food packages for the targeted conditions. Though MSF food packages do not need to meet minimum nutrient and energy requirements, MSF Community Supports Providers should design food packages to support participants to meet minimum recommendations for fruit, vegetable, or other targeted daily servings for nutrients. MSF must not contain ultra-processed foods nor foods with excessive sugar or salt. 

Terms within the category of MSF are defined as follows: 

1. Medically Supportive Groceries: Preselected foods that follow the federal Dietary Guidelines for Americans and meet recommendations for the nutritionsensitive health conditions of the recipients to whom they are prescribed. 
2. Produce Prescriptions: Fruits and vegetables, typically procured in retail settings, such as grocery stores or farmers’ markets, obtained via a financial mechanism such as a physical or electronic voucher or card.
3. Healthy Food Vouchers: Vouchers used to procure pre-selected foods that follow the federal Dietary Guidelines for Americans and meet recommendations for the nutrition-sensitive health conditions of the recipients, via retail settings such as grocery stores or farmers’ markets. 
4. Food Pharmacy: A model that specifically combines MSF and nutrition supports to remove barriers to healthy eating and build the knowledge and skills of participants to cook and eat foods appropriate for their nutrition-sensitive conditions. Food pharmacies are often housed within (or managed by) a health care setting, providing a patient cohort with coordinated clinical, food, and nutrition education services targeted at specific nutrition-sensitive health conditions. The healthy food “prescription” includes access to a selection of specific whole foods appropriate for the specific chronic or serious health condition(s) that follow the federal Dietary Guidelines for Americans and meet recommendations for the targeted health condition(s). The food is typically paired with peer supports, nutrition education, counseling, and/or culinary classes to build cooking and healthy eating skills and habits. 

MCPs must require and oversee that their MTM/MSF Providers produce MTM/MSF meal and food packages that follow national nutrition guidelines and that are appropriate for the nutrition-sensitive conditions identified by the MCP for MTM/MSF services. MTM/MTG and MSF service packages must be tailored or designed at the service level for the identified target chronic or serious health conditions (e.g., MSFs recommended and tailored for Members with chronic heart failure, or the Dietary Approaches to Stop Hypertension (DASH) diet for Members with hypertension who may benefit from a low sodium diet). Meals, groceries, produce prescriptions, or nutritional intervention packages do not need to be individually customized for each Member, but must be appropriate based on evidence-based guidelines for the targeted nutrition-sensitive health conditions(s) for which the MTM/MSF service is intended to improve. MCPs and their MTM/MSF Community Support Providers must consider the cultural preferences/needs (e.g., halal or kosher meals) and food preparation and storage capabilities (e.g., ability to store frozen meals) of each individual Member when determining the appropriate MTM/MSF intervention for the Member. 

Nutrition Education: Health coaching, counseling, classes, behavioral supports, and tools, including equipment and materials, that are based on a Member’s health conditions and needs. DHCS strongly encourages, but does not require, MCPs to work with their Community Supports Providers to offer behavioral, cooking, and/or nutrition education as part of this service alongside the MTM/MSF services offered. Nutrition education provided as a standalone service is not sufficient to be considered delivery of this Community Support. 

• Any nutrition education offered must adhere to nationally-established, evidence-based nutrition guidelines and be vetted by an RDN or other appropriate clinician. The education must be appropriate to the Member’s chronic or serious health condition and the MTM/MSF intervention the Member is receiving. Nutrition education can be provided in an individual or group setting. Nutrition education classes do not need to be delivered by an RDN. The organization delivering nutrition education may be the same as the organization providing the MTM/MSF but is not required to be the same organization. An MCP may choose to provide nutrition education directly. 
• Nutrition education provided as part of this service does not supplant other Medi-Cal services. MCPs are encouraged to identify and refer Members who are receiving MTM/MSF Community Support services to other Medi-Cal covered services for which they may be eligible such as Medical Nutrition Therapy and Diabetes Self-Management Education. 

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Medically Tailored Meals and Medically Supportive Food Community Support Referral form.

Asthma Remediation can prevent acute asthma episodes that could result in the need for emergency services and hospitalization. The Asthma Remediation Community Support consists of supplies and/or physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of a Member, or to enable a Member to function in the home with reduced likelihood of experiencing acute asthma episodes. 

Asthma Remediation should supplement the Asthma Preventive Services (APS) Medi-Cal State Plan service. APS covers clinic-based asthma self-management education, home-based asthma self-management education, and in-home environmental trigger assessments that identify physical modifications to a home or supplies that would reduce the likelihood of acute asthma episodes. 

Effective January 1, 2026: Removal of In-Home Environmental Trigger Assessments and Asthma Self-Management Education from the Asthma Remediation Community Support DHCS launched the APS benefit in July 2022, six months after the Asthma Remediation Community Support. The CalAIM Special Terms and Conditions require that Community Supports must supplement and not supplant services received by the MediCal Member through other State, local, or federally funded programs. To implement this requirement, DHCS is updating Asthma Remediation Community Support effective January 1, 2026: asthma self-management education and in-home environmental trigger assessments must be covered by MCPs under the APS benefit and will no longer be covered under this Community Support. 

DHCS is providing a phase-out period for asthma self-management education and inhome environmental trigger assessments from the Asthma Remediation Community Support to allow Community Supports Providers that are not currently enrolled with the Medi-Cal program to enroll and seek reimbursement under APS. Throughout 2025, MCPs may still cover asthma self-management education and in-home environmental trigger assessments under the Asthma Remediation Community Support as long as the Member meets eligibility criteria as outlined below. 

Supplies and physical modifications for Asthma Remediation covered under this Community Support include, but are not limited to: 

• Allergen-impermeable mattress and pillow dustcovers 
• High-efficiency particulate air (HEPA) mechanical filtered vacuums 
• Integrated Pest Management (IPM) services
• De-humidifiers 
• Mechanical air filters/air cleaners
• 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 for the management and treatment of asthma

 The services are available in a home that is owned, rented, leased, or occupied by the Member or their caregiver. Services provided to a Member need not be carried out at the same time but may be spread over time, subject to lifetime maximums below.

From January 1, 2025 to December 31, 2025, MCPs should transition coverage for inhome environmental trigger assessments and asthma self-management education to the APS benefit but may cover the following under the Community Support, as medically necessary, through December 31, 2025:

• In-home environmental trigger assessments are defined as the identification of environmental asthma triggers commonly found in and around the home, including allergens and irritants. This assessment guides the supplies, home modifications, and asthma self-management education about actions to mitigate or control environmental exposures offered to the Member. 
• Asthma self-management education can include, but is not limited to: 
  • Teaching Members how to manage their asthma, including how to use inhalers 
  • Teaching Members how to identify environmental triggers commonly found in their own home, including allergens and irritants 
  • Informing Members about various options for reducing environmental triggers such as using dust-proof mattresses and pillow covers, asthma-friendly cleaning products, air filters, etc.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Asthma Preventive Services (APS) Referral form. An APS provider will assist with coordinating this Community Support.

Housing Transition Navigation Services (HTNS) assist Members with finding, applying for, and obtaining housing. The services provided to a Member must be based on an individualized assessment of needs and documented in the Member’s housing support plan. As such, a Member may only require a subset of the following activities. 

HTNS activities include: 

 1. Conducting a housing assessment that identifies the Member’s preferences and barriers related to successful tenancy. The assessment may include collecting information on the Member’s housing needs and preferences, potential housing transition strengths and barriers, and identification of housing retention strengths and barriers. 
2. Developing a housing support plan based upon the housing assessment. 
3. Assisting in searching for housing and presenting options. 
4. Assisting in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history). 
5. Assisting with benefits advocacy, including assistance with obtaining identification and documentation for Supplemental Security Income (SSI) eligibility and supporting the SSI application process. Such service can be subcontracted out to retain any needed specialized skillset. 
6. Identifying and securing available resources to assist with attaining housing—such as Transitional Rent, HUD Housing Choice Voucher, and other state and local assistance programs—and matching available resources to Members. 
7. Identifying and securing resources including but not limited to Housing Deposits, to cover expenses such as security deposit, moving costs, adaptive aids, environmental modifications, moving costs, and other one-time expenses.
8. Providing education to the Member about Fair Housing and anti-discrimination practices, including making requests for necessary reasonable accommodation if necessary. 
9. Landlord education and engagement. 
10. Ensuring that the living environment is safe and ready for move-in. 
11. Communicating and advocating on behalf of the Member with landlords. 
12. Assisting in, arranging for, and supporting the details of the move. 
13. Establishing procedures and contacts to retain housing, including developing a housing support crisis plan that includes prevention and early intervention services when housing is jeopardized. 
14. Identifying, coordinating, securing, or funding non-emergency, non-medical transportation to assist Members’ mobility to ensure reasonable accommodations and access to housing options prior to transition and on move in day.
15. Identifying, coordinating, securing, or funding environmental modifications to install necessary accommodations for accessibility (see Environmental Accessibility Adaptations).

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Housing Transition Navigation Services (HTNS) Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

Housing Deposits assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household. The services and goods provided to a Member must be based on an individualized assessment of needs and documented in the Member’s housing support plan. As such, a Member may only require a subset of these services/goods. 

Housing Deposits include:

1. Security deposits required to obtain a lease on an apartment or home. 
2. Set-up fees/deposits for utilities or service access and payment in utility arrears. 
3. First month coverage of utilities, including but not limited to telephone, gas, electricity, heating, and water.
4. Services necessary for the individual’s health and safety, such as pest eradication and one-time cleaning prior to occupancy, along with necessary minor repairs to meet HUD Housing Choice Voucher program quality standards, or other habitability standards, as applicable, where those costs are not the responsibility of the landlord under applicable law. 
5. Application fees to cover the cost of the lease application. 
6. Goods such as an air conditioner or heater, and other medically-necessary adaptive aids and services, designed to preserve an individuals’ health and safety in the home such as hospital beds, Hoyer lifts, air filters, specialized cleaning or pest control supplies etc., that are necessary to ensure access and safety for the individual upon move-in to the home, when they are not otherwise available to the Member under Medi-Cal.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Housing Deposits Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

Housing Tenancy and Sustaining Services (HTSS) help a Member maintain safe and stable tenancy once housing is secured. The services provided to a Member must be based on an individualized assessment of needs and documented in the Member’s housing support plan. As such, a Member may only require a subset of the following activities. 

HTSS activities include:

1. Providing early identification and intervention for behaviors that may jeopardize housing, such as late rental payment, hoarding, substance use, and other lease violations. 
2. Providing education and training for the Member on the role, rights, and responsibilities of the tenant and landlord. 
3. Providing education for the Member about Fair Housing and anti-discrimination practices, including making requests for necessary reasonable accommodation if necessary. 
4. Coaching on developing and maintaining key relationships with landlords/property managers and/or neighbors with a goal of fostering successful tenancy. 
5. Coordinating with the landlord and care/case management provider, which can be the Member’s ECM Provider or non-Medi-Cal housing supportive services providers such as a CoC program case manager, to address identified issues that could impact housing stability. 
6. Assistance in resolving disputes with landlords and/or neighbors to reduce risk of eviction or other adverse action including developing a repayment plan or identifying funding in situations in which the Member owes back rent or payment for damage to the unit.
7. Advocacy and linkage with community resources to prevent eviction when housing is or may potentially become jeopardized. 
8. Assisting with benefits advocacy, including assistance with obtaining identification and documentation for SSI eligibility and supporting the SSI application process. Such service can be subcontracted out to retain any needed specialized skillset. 
9. Assistance with the annual housing recertification process. 
10. Coordinating with the tenant to review, update, and modify their housing support and crisis plan on a regular basis to reflect current needs and address existing or recurring housing retention barriers. 
11. Continuing assistance with lease compliance, including ongoing support with activities related to household management. 
12. Health and safety visits, including to ensure the unit remains safe and habitable. 
13. Other prevention and early intervention services identified in the crisis plan that are activated when housing is jeopardized (e.g., assisting with reasonable accommodation requests that were not initially required upon move-in). 
14. Providing independent living and life skills including assistance with and training on budgeting, including financial literacy and connection to community resources.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Housing Tenancy and Sustaining Services (HTSS) Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

Day Habilitation Programs are designed to assist a Member in acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary to reside successfully in the person’s natural environment. The service is provided in a Member’s home or an out-of-home, non-facility setting. The services are often considered peer mentoring when provided by an unlicensed caregiver with the necessary training and supervision. For Members experiencing homelessness who are receiving ECM or other Community Supports, Day Habilitation Programs can provide a physical location for the provision of Day Habilitation services. When possible, ECM and the other Community Supports should be provided by the same entity that is providing Day Habilitation to minimize the number of care/case management transitions experienced by Members and to improve overall care coordination and management. 

Day Habilitation Program services include, but are not limited to, training on:

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

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

1. Selecting and moving into a home. 
2. Locating and choosing suitable housemates. 
3. Locating household furnishings. 
4. Settling disputes with landlords.
5. Managing personal financial affairs. 
6. Recruiting, screening, hiring, training, supervising, and dismissing personal attendants. 
7. Dealing with and responding appropriately to governmental agencies and personnel. 
8. Asserting civil and statutory rights through self-advocacy. 
9. Building and maintaining interpersonal relationships, including a circle of support. 
10. Coordinating with the MCP to link the Member to any Community Supports services and/or ECM.
11. Providing a referral to non-Community Supports housing resources if the Member does not meet the eligibility criteria for HTNS, Housing Deposits, HTSS, or Transitional Rent. 
12. Assisting with income and benefits advocacy including General Assistance/ General Relief and SSI if the Member is not receiving these services through Community Supports or ECM. 
13. Coordinating with the MCP to link the Member to health care, mental health services, and substance use disorder services based on the individual needs of the Member for Members who are not receiving this linkage through Community Supports or ECM.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Day Habilitation Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

Recuperative Care, also referred to as medical respite care, is for individuals who are experiencing or at risk of homelessness and need a short-term residential setting in which to recover from an injury or illness (including a behavioral health condition).A stay in a Recuperative Care setting allows an individual to recover from an injury or illness while also obtaining access to primary care, behavioral health services, case management, and other supportive social services, such as transportation, food, and housing. It is for individuals who have medical needs significant enough to result in emergency department (ED) visits, hospital admissions, or other institutional care. 

At a minimum, the service will include interim housing with a bed and meals and ongoing monitoring of the individual’s ongoing medical or behavioral health condition (e.g., monitoring of vital signs, assessments, wound care, medication monitoring). Based on individual needs, the service may also include:

 1. Limited or short-term assistance with Instrumental Activities of Daily Living (IADLs) and/or Activities of Daily Living (ADLs) to the extent permitted by licensure (see below). 
2. Coordination of transportation to post-discharge appointments. 
3. Connection to any other ongoing services an individual may require, including mental health and substance use disorder services. 
4. Support in accessing benefits and housing. 
5. Gaining stability with case management relationships and programs.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Recuperative Care (Medical Respite) Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

 

 

Short-Term Post-Hospitalization Housing provides Members who are exiting an institution and experiencing or at risk of homelessness with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting the institution. This would include recuperative care facilities (including facilities covered under Community Support Recuperative Care or other facilities outside of Medi-Cal), inpatient hospitals (either acute or psychiatric or Chemical Dependency and Recovery hospital), residential substance use disorder or mental health treatment facility, correctional facilities, or nursing facilities. To be eligible, an individual must have ongoing physical or behavioral health needs as determined by a qualified health professional that would otherwise require continued institutional care if not for receipt of Short-Term Post-Hospitalization Housing. 

The Short-Term Post-Hospitalization Housing setting must provide Members with ongoing supports necessary for recuperation and recovery, such as gaining (or regaining) the ability to perform activities of daily living, receiving necessary medical/psychiatric/substance use disorder care, receiving case management, and beginning to access other housing supports such as HTNS. 

Short-Term Post-Hospitalization Housing settings may include a private or shared interim housing setting, where residents receive the services described above.

If you are a member seeking services, please call 1-877-661-6230, Option 2, Monday through Friday, 8 AM to 5 PM. If you are a provider, please complete our Short-Term Post-Hospitalization Housing Community Support Referral form and our Homelessness Risk Assessment Referral Supplement.

This session provides an essential guide to navigating the wide range of behavioral health and substance use services available to individuals. Learn how to connect clients with the right resources, including mental health services, addiction treatment, and specialized programs for recovery and support.

  

CalAIM Educational Series Part 1 Slide Deck

This session provides a comprehensive overview of key systems and services that support children with behavioral health needs, developmental delays or disabilities, and early childhood support. Learn how to navigate programs, make effective referrals, and empower families with the right tools—right from the start.

 

CalAIM Educational Series Part 2 Slide Deck

This session is designed to help staff and partners understand the systems of care that work together to support vulnerable children and families. From child welfare to specialized healthcare programs, learn how to coordinate services, engage families, and ensure no child falls through the cracks.

 

CalAIM Educational Series Part 3 Slide Deck

This session explores how CCHP supports members across every stage of their health journey—from prenatal care to managing chronic conditions and coordinating complex needs. Learn how education, resources, and telephonic case management programs help members reach their health goals with confidence and compassion.

 

CalAIM Educational Series Part 4 Slide Deck

This session is designed to help providers and care managers guide members through the essential services offered by CCHP. Explore key topics such as Member Services, Non-Medical and Non-Emergency Medical Transportation (NMT & NEMT), and Medi-Cal Rx Pharmacy Benefits. Learn how to effectively connect your patients with these services, understand coverage details, and optimize care coordination. Empower yourself with the tools and knowledge to enhance patient outcomes and streamline the care management process.

 

CalAIM Educational Series Part 5 Slide Deck

This session offers a comprehensive overview of the key programs and services available to individuals experiencing homelessness in Contra Costa County. This session will guide you through essential resources and initiatives, showing how outreach, healthcare, housing, and support services work together to help individuals regain stability and build a better future.

 

CalAIM Educational Series Part 6 Slide Deck

This session provides an in-depth look at programs that support older adults and individuals with disabilities in living safely and independently in the community. Learn about the benefits, eligibility, and application processes for critical Home and Community-Based Services.

 

CalAIM Educational Series Part 7 Slide Deck

This session provides an overview of essential programs that support the health and well-being of families, mothers, and children. Learn about key initiatives aimed at improving maternal health outcomes, promoting infant care, and ensuring families receive the support they need. Explore lactation resources available to new parents, including breastfeeding support programs that help establish healthy feeding practices for optimal infant health. Discover resources tailored for fathers, designed to support their involvement in prenatal and postnatal care, strengthen father-child relationships, and promote overall family well-being.

 

CalAIM Educational Series Part 8 Slide Deck

This session provides a comprehensive overview of critical services designed to support individuals transitioning from incarceration. Learn about programs that offer pre-release planning, post-release support, and opportunities for successful reintegration into the community.

 

CalAIM Educational Series Part 9 Slide Deck