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HomeMy WebLinkAboutmedically-frail-presentationMedically Frail Housing Program Updated December 2025 2 What is Medically Frail Housing? During the COVID-19 pandemic, a need was identified for unhoused people with very complex medical conditions, some of whom are not prioritized for housing through the current housing assessment and some of whom need more medical support than offered in traditional permanent supportive housing. In response to this need: 1.Medically frail housing was developed. This is permanent and interim housing with additional on-site services (nursing and personal care as needed) that allow members to live independently. 2.The CoC System Coordination Committee approved a Medically Frail prioritization policy that prioritizes unhoused people with complex medical conditions for designated “medically frail” housing. 3.This referral system is part of the coordinated entry system and runs in parallel with other resources prioritized through the housing assessment. 3 Who is this Housing Designed For? Individuals with Significant Functional Limitation, including those with: ✓Limited ability to complete Activities of Daily Living (ADLs) independently. -ADLs are defined as walking, feeding oneself, dressing and grooming, toileting, bathing, or transferring (from chair to bed). ✓Rely on assistive devices including a walker or wheelchair or are bedbound by illness or disability. ✓Severe mental illness (complicated by or complicating other medical conditions), traumatic brain injury or other cognitive disability 4 Housing Types Interim Housing –Medically Enhanced Permanent Housing –Medically Frail Housing Type Shelters/Transitional housing –currently Oakland site is accepting referrals. More county wide locations to open in 2026 •Client holds lease and pays 30% of income •Private bathroom Services Available •Nursing and personal care (RNs, LVNs, care giving staff. Not primary care services.) •Housing Navigation/case management •Nursing and personal care (RNs, LVNs, care giving staff. Not primary care services) •Tenancy Sustaining Services/case management Connection to Coordinated Entry •Not required for referral pathway via Medically Frail referral portal •Required for Crisis queue referral pathway •Onsite providers to assist with enrollment (for those from medically frail referral pathway) •Active enrollment in CE program in HMIS •Housing needs assessment within the past 180 days of referral Required Documents N/A VOI, VOD, VOH, ID, SS (dependent on site), medically frail referral form, property application, and others as required Locations Oakland site is accepting referrals. More county wide locations to open in 2026 Oakland, Hayward Referral Pathway •Medically Frail Referral Form •Crisis Queue Medically Frail Referral Form 5 Eligibility Requirements –Permanent Supportive Housing (PSH) Referrals must meet both of the following program eligibility criteria to be considered: 1)Homeless* Lacks a fixed, regular and adequate nighttime residence. The individual’s or household’s primary nighttime residence is: 1) a public or private place not meant for human habitation in Alameda County, OR 2) the individual or household is living in interim housing or is exiting an institution (jail, hospital, skilled nursing facility) and would be homeless at the time of discharge in Alameda County.) 2)Qualifying health condition that meets: a) frequent utilization* of Healthcare services, AND b) Significant functional limitations, AND c) Medical Complexity/Complex Chronic Illness *Individuals currently residing in PSH with clinical needs that exceed onsite support will be considered if individual meets other eligibility criteria *8 or more ED visits, OR 2 inpatient visits in the past 12 months 6 Eligibility Requirements –Medically Enhanced Interim Housing Referral eligibility criteria: 1)Homeless* Lacks a fixed, regular and adequate nighttime residence. The individual’s or household’s primary nighttime residence is: 1) a public or private place not meant for human habitation in Alameda County, OR 2) the individual or household is living in interim housing or is exiting an institution (jail, hospital, skilled nursing facility) and would be homeless at the time of discharge in Alameda County.) 2)Those who would benefit from a single room due to: 1)bowel or bladder control challenges 2)Disordered sleep that makes congregate shelter difficult 3)Use of durable medical equipment that cannot be safely used or stored in shelter or on the street (walker, oxygen equipment, special bed, wheelchair, etc.) 4)A level of medical support similar to respite services: chronic wound care, Post-surgical care, Short-term medication treatment (e.g., antibiotics, HCV treatment) 7 Frequently Asked Questions When will units be available? -Currently open and being on a rolling basis How many units will be available? -We don’t have an exact number,but we anticipate the resources growing over time. Where can I find the referral form? -https://forms.office.com/g/RqvqtxhjPt and is on the HCH website After submitting a referral, when should I expect to a response? -Within in 10 business days, you will be notified if client meets eligibility requirements or if additional information is needed to determine eligibility. How soon will someone be matched to a resource? -Referrals that meet the criteria will be prioritized for available resources based on severity of medical condition.The length of time is dependent on availability of resources. Health Care for the Homeless staff will be in continual contact with prioritized individuals to provide estimated match dates. 8 Frequently Asked Questions Continued What documents are needed to send with referral application? -A Release of Information (ROI) between the referring party and HCH is needed. It can be found on the Health Care for the Homeless website, https://www.achch.org/medically-frail-housing- information.html. -PSH –Once matched to a PSH resource, individuals will need an ID, Social security Number Verification (site dependent), Verification of Disability, Verification of current homelessness, Verification of Income,property application and others. What if the individual I'm working with is eligible but there are no units available? There is a queue which will be reviewed frequently, and matches will be made as units become available.Prioritization will be dynamic,and the primary factor will be severity of medical need.Housing needs assessment scores will be used as a tie-breaker. Please work on connecting to other resources as well as availability is limited. 9 Frequently Asked Questions Continued Do I need to be a healthcare provider to refer someone? No, referrals can be completed by any service provider who is serving people experiencing homelessness in Alameda County. What if the individual I am working with is currently residing in PSH with clinical needs that exceed onsite support. Is this an appropriate referral option? This MAY be appropriate if the individual meets other eligibility requirements. A Health and Safety Transfer will need to be completed. Reach out to homestretch@acgov.org if more information is needed. I am working with someone who is/will be recovering from a surgery or acute illness, is this appropriate for them? No, please have their medical provider refer them to Medical Respite. 10 Frequently Asked Questions Continued Does an individual need to switch their Housing Community Support (HCS) provider when they move into Medically Frail Housing? If the person is referred to a site with a site based HCS Tenancy Sustaining Service (TSS) Provider, they would need to transfer care to the TSS provider serving the site. Does the individual need to have Medi-Cal to be referred? No, however given the clinical complexity of individuals that medically frail housing is designed to served, individuals will need to be supported in obtaining Medi-Cal to access needed care. Are families eligible to be referred if the head of household is medically frail? Yes, it is ok to submit a referral. The majority of existing medically frail units have a maximum occupancy of one person, with no units currently able to support households larger than two people. 11 Frequently Asked Questions Continued I’m working with a minor that is medically frail, is this an appropriate resource for them? No. The individual I’m working with is a registered sex offender,Can I still refer them? Yes, this is not a barrier to referring into Medically Frail housing. However, once matched to a PSH site, the property will make the make final determinations for housing eligibility. Where on the referral form, can I select the option for PSH vs interim housing? Question 30 asks “are you interested in applying for interim, perm or first available.” 12 Thank you! Please reach out to ACHCHreferrals@acgov.org with questions.