The Skilled Nursing Facilities Transition Service Bundle works to obtain and maintain permanent housing for AC Care Connect clients in the community and shorten durations of stay in Skilled Nursing Facilities (SNFs) for clients who don’t have an ongoing medical need. The effort extends the Money Follows the Person Rebalancing Demonstration Program, or “California Community Transitions” (CCT), in Alameda County, which is administered by the California State Department of Health Care Services (DHCS). Under the CCT Program, clients are only eligible for case management services if they are Medi-Cal beneficiaries who have continuously resided in state-licensed health care facilities for a period of 90 consecutive days or longer. The Skilled Nursing Facilities Transition Service Bundle identifies clients as soon as they enter a SNF and immediately begins crafting a housing plan that provides an intensive level of housing navigation to help clients transition into the community as soon as possible.

Medi-Cal beneficiaries residing in a skilled nursing facility within Alameda County.

Housing navigation services are offered to at least 37 clients during the contract year in order to help clients transition into the community from a skilled nursing facility as soon as possible.