Enhanced Care Management and Community Supports

Medically Tailored Meals/Medically Supportive Foods

Poor nutrition can lead to poor health, especially for members with chronic conditions. Meals designed by dietitians can help these members reach their nutrition goals at critical times to help them regain and maintain their health. 

Members can get up to two (2) meals per day and / or up 13 boxes of groceries every 3 months, or longer if medically necessary.  Behavioral, cooking, and nutrition education are included.  Meals not covered are those that can be reimbursed by another program or those that solely address food insecurity.Eligible members must have one of these conditions:

• Gestational diabetes
• Obesity with a significant comorbidity
• Severe obesity
• Metabolic syndrome
• Pediatric obesity
• ESRD on dialysis
• poorly controlled diabetes for at least six (6) months, even after receiving education about diet, lifestyle, and medication OR
• poorly controlled heart failure (congestive heart failure) with an emergency department or inpatient hospitalization related to this condition in the last 6 months

Members who get this service will agree to enroll in and complete a diet & lifestyle education course to get ongoing services.  Members must also agree to and complete monthly visits with a dietitian who will continue to assess the need.

Members who are who are not eligible for this program include:

• Members who do not have access to food storage or preparation.
• Members in a skilled nursing facility (SNF), hospice, or incarcerated

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Asthma Home Remediation

Members with poorly controlled asthma may have asthma triggers in their home removed or reduced. Physical changes are made to the home environment to ensure the health and safety of the member. The changes enable these members to function in the home safely. Without these changes, the member’s asthma attacks can result in the need for emergency services or hospitalization.

Examples of environmental asthma trigger remediation include, but are not limited to:

• Allergen-impermeable mattress and pillow dustcovers
• High-efficiency particulate air (HEPA) filtered vacuums
• Integrated pest management (IPM) services
• Dehumidifiers
• 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

Members with poorly controlled asthma and stable housing are eligible for the service. Members have environmental asthma triggers identified through a home visit, and these triggers can be reduced or removed. Members agree to complete asthma education, including proper use of asthma medication.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Recuperative Care (Medical Respite)

Recuperative Care is also referred to as medical respite care. It is short‐term residential care primarily used for individuals who are experiencing homelessness or those with unstable living situations, who are not ill enough to be in a hospital, but are too ill or frail to recover from an illness (physical or behavioral health) or injury in their usual living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post‐discharge treatment while getting access to primary care, behavioral health services, case management, and other supportive social services (e.g, transportation, food, and housing).

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).

The members must be members who can live independently without formal supports and:

• Be exiting an inpatient hospital stay, long-term care facility, or skilled nursing facility, or is at risk of hospitalization
• Not be medical appropriate for a skilled nursing facility
• Be able to live independently (e.g., does not require 24/7 care and supervision, not appropriate for an Adult Residential Facility (ARF), etc.)
• Be experiencing homelessness, at risk of homelessness, or face housing insecurity, or have housing that would harm their health and safety without modification.  (Please note: There are additional criteria for members experiencing homelessness and at risk of homelessness.)
• Have a defined home health skilled need that is appropriate for respite that can be effectively addressed in six (6) weeks or less (e.g, physical therapy, occupational therapy, speech therapy, or wound care)
• Be medically appropriate for respite

Authorization cannot exceed 90 consecutive days and member may not be receiving duplicate support from other state, local, or federally funded programs.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Short-Term Post-Hospitalization Housing

Short-Term Post-Hospitalization Housing helps members experiencing or at risk of homelessness, who also have high medical or behavioral health needs. This service gives the opportunity for these members to continue their medical, psychiatric, or substance use disorder recovery in a housed setting with necessary supports to help with their recovery immediately after exiting a hospital. This service also enables these members to receive necessary care, case management, and begin to access other housing supports, such as Housing Transition Navigation.

The members must be individuals who are experiencing or at risk of homelessness and:

1. Be exiting recuperative care or
2. Be exiting an inpatient hospital stay, long-term care facility, residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, skilled nursing facility, or emergency department, and meet at least one of the following:
   1. Experiencing homelessness and at least one of the following:
      1. Receiving Enhanced Care Management (ECM)
      2. Have at least one serious chronic condition and/or serious mental illness and are at risk of institutionalization
      3. Requiring residential services due to a substance use disorder
   2. At risk of homelessness and at least one of the following:
      1. Have at least one serious chronic condition and/or serious mental illness
      2. Are at risk of institutionalization, overdose, or require residential services due to a substance use disorder, or have a serious emotional disturbance
      3. Are receiving Enhanced Care Management (ECM)
      4. Are transition-age youth with significant barriers to housing stability
3. Have high medical or behavioral needs
4. Be able to benefit from ongoing supports for recuperation and recovery, and other housing supports
5. Agree to Housing Transition Navigation Services support
6. Not have financial means to go elsewhere (e.g., motel, hotel, SRO, etc.)
7. Not be receiving duplicate support from other local, state, or federally funded programs
8. Not have previously received this service and failed to cooperate in good faith with Housing Transition Navigation Services and Housing and Tenancy Sustaining Services

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Housing Transition Navigation Services

Housing Transition Navigation Services helps members with obtaining housing. It includes screenings, development of housing support plans, help with searches for and securing housing, identifying and securing financial resources for housing, communicating with landlords, helping with the move, and more. Services are based on the member's needs documented in the individualized housing support plan.

To be eligible, members must:

• Be prioritized for permanent supportive housing or a rental subsidy resource through the local Coordinated Entry System or
• Be experiencing or at risk of homelessness and at least one of the following:
  • Have at least one serious chronic condition and / or serious mental illness
  • Are at risk of institutionalization or overdose or requires residential services due to a substance use disorder or have a serious emotional disturbance 
  • Are receiving Enhanced Care Management (ECM)
  • Are transition-age youth with significant barriers to housing stability
• Not be receiving duplicate support from other local, state, or federally funded program

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Housing and Tenancy Sustaining Services

This service provides tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured. Services include identification, education, and intervention surrounding behaviors and needs that may jeopardize housing, help with finances and landlord or neighbor disputes, health and safety visits, and more. Services are based on the member's needs documented in the individualized housing support plan.

To be eligible, members must:

• Have received Housing Transition Navigation Services
• Are prioritized for a permanent supportive housing unit or rental subsidy through the local homeless Coordinated Entry System
• Be experiencing or at risk of homelessness and at least one of the following:
  • Have at least one serious chronic condition and / or serious mental illness
  • Are at risk of institutionalization or overdose or requires residential services due to a substance use disorder or have a serious emotional disturbance 
  • Are receiving Enhanced Care Management (ECM)
  • Are transition-age youth with significant barriers to housing stability
• Not have previously received this service, unless good cause is shown as to why additional services would be beneficial and that the member did not lose previous housing due to unwillingness to cooperate in good faith with necessary actions required for this service
• Not be receiving duplicate support from other local, state, or federally funded program

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Housing Deposits

This service assists with identifying, coordinating, securing, or funding one-time services and modifications needed to enable a person to establish a basic household. It does not include room and board or payment of ongoing rental costs.

Housing deposits may include:

• Security deposits required to obtain or lease an apartment or home
• Set-up fees / deposits for utilities or service access
• First month coverage of utilities Including, but not limited to telephone, gas, electricity, heating, and water
• First and last month’s rent
• Services necessary for the member’s health and safety (e.g., one-time cleaning, getting rid of pests)
• Goods such as air conditioner or heater, and other medically-necessary adaptive aids and services for the member’s health and safety in the home (e.g., hospital beds, Hoyer lifts, air filters, specialized cleaning or pest control supplies)

Services are based on the member's needs documented in the individualized housing support plan.

Housing Deposits are available once in a member’s lifetime. It can only be approved an additional time with documentation as to what conditions have changed showing why providing this service a second time would be more successful than the first time.

These services must be identified as reasonable and necessary in the member’s individualized housing support plan and available only if the member is unable to meet the expense.

To be eligible, members must:

• Have received Housing Transition Navigation Services or
• Be prioritized for a permanent supportive housing unit or rental subsidy through the local Coordinated Entry System or
• Be experiencing homelessness and at least one of the following:
  • Have at least one serious chronic condition and / or serious mental illness
  • Are at risk of institutionalization or overdose or requires residential services due to a substance use disorder
  • Are receiving Enhanced Care Management (ECM)
• Provide income and housing subsidy verification if applicable

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service. You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Respite Services 

Respite Services are provided to caregivers of members who require intermittent temporary supervision.  It is short-term relief for the caregiver to prevent burnout and is useful and necessary to allow a member to stay in their own home.

To be eligible, members must live in the community and need help with Activities of Daily Living (ADLs) from a caregiver who provides most of their support and who needs relief in order to avoid having the member placed in a facility for which Medi-Cal managed care would be responsible.

Services in the home in combination with any direct care services the member is receiving, cannot exceed 24 hours per day of care.  The service limit is 336 hours per calendar year, inclusive of all in-home and in-facility services.  Respite services cannot be provided virtually or via telehealth.

The member may not receive duplicate support from other state, local, or federally funded programs.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Personal Care and Homemaker

Personal care services and homemaker services are for members who need help with:

• Activities of Daily Living (ADLs) such as bathing, dressing, toileting, ambulation, or feeding. 
• Instrumental Activities of Daily Living (IADLs) such as meal preparation, grocery shopping, and money management. 
• Tasks such as cleaning and shopping, laundry, and grocery shopping. 

Personal care and homemaker programs help members who otherwise would not be able to stay in their homes.

To be eligible, members must:

• Be at risk for hospitalization or placed in a nursing facility or
• Have functional needs and no other adequate support system or
• Be approved for In-Home Support Services (IHSS)

The service cannot be used instead of the IHSS program.  The member must be referred to the IHSS program when they meet referral criteria. Similar services available through IHSS must be used first.  The Personal Care and Homemaker Services should only be used if appropriate and if additional hours or supports are not authorized by IHSS.  Members who receive Personal Care and Homemaker Services who have any change in their current condition must be referred to IHSS for a reassessment for additional hours.  They may continue to get Personal Care and Homemaker Services during the reassessment waiting period.  Members may not receive duplicate support from other state, local, or federal funded programs.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Environmental Accessibility Adaptations (Home Modifications)

Environmental Accessibility Adaptations (EAAs) or Home Modifications are physical changes to a home.  These are changes that are needed to ensure the health and safety of a member and allow them to live more independently at home instead of in a nursing facility.  Example home modifications include ramps, grab bars, chair / stair lifts, door widening for those who use a wheelchair, or installation of a Personal Emergency Response System.

Members who are at risk for institutionalization in a nursing facility are eligible.  The services are available in a home that is owned, rented, leased, or occupied by the member.  For a home not owned by the member, the member must get written consent from the owner for physical changes to the home.

There is a lifetime maximum of $7,500 for EAAs (Home Modifications).  Changes are limited to those with a direct medical or remedial benefit to the member and exclude changes that are of general utility to the household.  Members may not receive duplicate support from other state, local, or federal funded programs.  Other programs should be used first.  

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Nursing Facility Transition / Diversion to Assisted Living Facilities (e.g., Residential Care Facilities for Elderly (RCFE) or Adult Residential Care Facilities (ARF))

This service helps members live in a home-like, community setting and / or prevent them from having to go to a skilled nursing facility.  The assisted living provider will be responsible for meeting the needs of the member (e.g., Activities of Daily Living (ADLs), Instrumental ADLs (IADLs), meals, transportation, and medication administration).  Members are directly responsible for paying their own living expenses.  

Members must have resided at least 60 days in a nursing facility or be currently receiving or eligible for nursing facility level of care services and be willing and able to reside safely in an assisted living facility. 

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Community Transition Services / Nursing Facility Transition to a Home

Community Transition Services pays for one-time set up expenses for members who are transitioning from a licensed facility to a living arrangement in a private residence where they are directly responsible for his or her own living expenses.  This allows the member to live in the community instead of a skilled nursing facility. 

Allowable expenses are those necessary to enable someone to establish a basic household that do not include room and board.  It includes:

• Identifying housing needs and options
• Helping to search for and secure housing 
• Communicating with the landlord and coordinating the move 
• Establishing procedures and contacts to retain housing
• Coordinating non-emergency, non-medical medical transportation prior to the transition and on move-in day
• Identifying the need for and coordinating funding for services and modifications necessary to establish a basic household (See Community Supports Housing Deposits section)

There is a total lifetime maximum of $7,500 for Community Transition Services.  These services are not for paying monthly rental or mortgage expenses, food, regular utility charges, household appliances, or items that are for fun and not necessary.

Members must have either resided at least 60 days in a nursing home or medical respite setting or be currently receiving nursing facility level of care services.  They must also be interested in and be able to safely reside in the community with appropriate cost-effective supports and services.

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).

Day Habilitation Program services support members’ independence in the community. 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; daily living skills (cooking, cleaning, shopping, money management); and community resource awareness such as police, fire, or local services.  The program may also provide help with selecting and moving into a home, finding and choosing suitable housemates, finding household goods and furniture, settling disputes with landlords, and managing personal finances.

To be eligible, members must:

• Be experiencing or at risk of homelessness or 
• Exited homelessness and entered housing in the last 24 months or
• Have housing stability that can be improved by participating in a Day Habilitation Program.

Members may not receive duplicate support from other state, local, or federal funded programs.  

Talk to your case manager, PCP, or other provider about getting a referral to enroll in this service.  You can also call CCHP Member Services, Monday – Friday, 8am – 5pm, at 1-877-661-6230 (press 2) (TTY 711).