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Housing Community Supports
(HCS) Provider Manual
Alameda County Health
Housing and Homelessness Services
2025 Contract Year
Published September 8, 2025, version 5.0
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Table of Contents
Glossary/Acronyms ....................................................................................................................................... 1
A. Introduction and Program Overview .................................................................................................... 1
1. Program Description ......................................................................................................................... 1
2. Roles and Responsibilities ................................................................................................................. 2
3. Who to Contact ................................................................................................................................. 4
B. Scope of Services................................................................................................................................... 4
C. Requirements to Complete Prior to Contract Execution ...................................................................... 4
1. Credentialing Requirements ............................................................................................................. 4
2. Agency Staffing Plan .......................................................................................................................... 5
3. Agency Training Plan ......................................................................................................................... 5
D. Training Requirements .......................................................................................................................... 6
E. Program Guidelines ............................................................................................................................... 6
1. Eligibility ............................................................................................................................................ 6
2. Housing Community Supports Referrals ........................................................................................... 7
3. Enrollment in Housing Community Supports ................................................................................. 10
4. Service Requirements ..................................................................................................................... 10
5. Housing Deposits ............................................................................................................................. 17
6. Housing Support Plan ...................................................................................................................... 19
7. Housing Community Supports Project Exits .................................................................................... 20
8. HMIS Guidelines and Requirements................................................................................................ 21
9. Coordination with other Service Providers ..................................................................................... 21
10. Documentation ............................................................................................................................... 22
F. Reporting, Quality Assurance, and Quality Improvement .................................................................. 22
1. Audit Protocol ................................................................................................................................. 22
2. Quality Measurement and Improvement ....................................................................................... 23
3. Grievances ....................................................................................................................................... 24
G. Data, Invoicing, and Payment Guidelines ........................................................................................... 24
1. Services-As-Needed Contracts ........................................................................................................ 24
H. Appendices .......................................................................................................................................... 27
1. Alliance Organization Provider Application (pages 3-5) .................................................................. 27
2. Community Support and ECM Organization Attestation (page 6) ................................................... 30
3. Staffing Plan Template ..................................................................................................................... 31
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4. Staff Training Plan Template ........................................................................................................... 32
5. Verbal Consent Guidelines .............................................................................................................. 33
6. Invoice Template ............................................................................................................................. 35
7. Quarterly Audit Protocol ................................................................................................................. 36
8. Example Housing Support Plan ....................................................................................................... 39
9. Contractor Dashboard..................................................................................................................... 43
10. Job Aid: HCS Project Entry in HMIS ................................................................................................. 48
11. Job Aid: Documenting Housing Community Support Services in HMIS .......................................... 51
12. Job Aid: HCS Dual Enrollment Report.............................................................................................. 55
13. Job Aid: Uploading Housing Support Plans to HMIS ....................................................................... 57
14. TSS Evaluation How-To ................................................................................................................... 58
15. Outreach Policy: Pre-Enrollment ..................................................................................................... 61
16. Grievance Policy .............................................................................................................................. 64
17. HCS Policy: PMPM Reimbursement for Consumers Without a Documented TSS Evaluation ........ 68
18. HMIS Guidance and Payment Summary ......................................................................................... 70
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Glossary/Acronyms
Acronym Definition
A. Introduction and Program Overview
1. Program Description
Alameda County Health (ACH) manages the delivery of Housing Community Supports (HCS) in Alameda
County. HCS includes:
• Housing Transition Navigation Services (HN)
• Housing Tenancy and Sustaining Services (TSS); and
• Housing Deposits (HD)
This Provider Manual serves as a guide for provider agencies contracted with ACH to provide Housing
Community Supports; the Provider Manual is intended as a supplement to HCS contracts executed
between the County and provider agencies. Contractors (contracted provider agencies) who receive
Summary of Changes
• Additional information added regarding what qualifies as a billable encounter (Section E-4)
• Reverse Referrals Policy added (Section E-2)
• Additional information added regarding consumer reassignment (Section E-2)
• Audit Protocol has been edited for clarity
• Outreach Policy (Appendix 15) has been updated to reflect data entry guidelines
• Appendix 17 updated to reflect policies for PMPM Reimbursement for Consumers Without a
Housing Support Plan
• New Appendix (18) added with detailed guidance on how to log pre-enrollment outreach and
billable encounters in HMIS
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funding for Housing Community Supports are expected to deliver the services and supports their
consumers need to obtain and keep housing, subject to the availability of ongoing funding.
Consumers are prioritized for Housing Community Support services through Coordinated Entry (also
administered by ACH) and are homeless, and formerly homeless households living in, or transitioning to
permanent housing within Alameda County.
ACH serves as the administrator for the Managed Care Plans (MCPs) to deliver Housing Community
Supports (HCS) to Medi-Cal managed care members. As such, ACH and its HCS contractors must adhere
to the state’s guidelines under California Advancing and Innovating Medi-Cal (CalAIM), the State’s multi-
year plan to transform the Medi-Cal program. This includes the implementation of housing community
supports as services designed to address social drivers of health, under Medi-Cal managed care,
beginning January 1, 2022.
Housing Community Supports program objectives include:
• Utilizing Housing First principles to help homeless and formerly homeless households obtain,
move into, and keep their homes;
• Outreaching to and engaging households referred by ACH to support a transition from
homelessness into permanent housing;
• Providing Housing Transition Navigation (HN) services to consumers experiencing homelessness
to support obtaining permanent housing in accordance with the DHCS Policy Guide;
• Providing supportive services to housed consumers enrolled in Housing Tenancy and Sustaining
Services (TSS) in accordance with the DHCS Policy Guide;
• Reducing utilization of crisis and inpatient health care resources among those receiving services;
• For housed consumers, interfacing regularly with property management/landlords, intervening
early when housing issues arise, and providing support to all consumers regarding housing
concerns and housing rights;
• Capturing real-time data in the Homeless Management Information System (HMIS) including
information about enrollment, service needs and provisions, changes in current living situation,
and performance outcomes, on all consumers served.
For more information about service standards specific to Housing Navigation and Tenancy Sustaining
Services, please see the Alameda County Homelessness Response System Written Standards.
2. Roles and Responsibilities
Agency/Department Role
Alameda County Health
(ACH) • Coordinates countywide homeless services
• Develops and implements Countywide Homeless Strategic Plan
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Agency/Department Role
•
• Serves as Management Entity for Coordinated Entry
• Contracts with Managed Care Plans to serve as the administrator
of Housing Community Supports for managed care members
• Oversees Housing Community Supports
• Provides programmatic oversight and compliance for the
Housing Community Supports program
• Continuum of Care (CoC) HUD Collaborative Applicant
• Administers HUD grants for rental assistance and services
• Serves as HMIS Management Entity
Data Exchange Unit (DEU)
• Uses SHIE and HMIS data to prepare claims, invoicing, and
encounter data for submission to the Managed Care Plans
• Uses SHIE and HMIS data to prepare reports for contractor
payment
California Department of
Health Care Services (DHCS)
•
California)
• Contracts with Managed Care Plans and counties to deliver
health care services to beneficiaries enrolled in Medi-Cal
• Oversees and implements policies for the delivery of health care
services under the Medi-Cal program
Managed Care Plan (MCP)1
•
services and supports including Enhanced Care Management
(ECM) for Alameda County residents enrolled in Medi-Cal
managed care
• Contracts with providers to deliver those services
• Contracts with ACH to provide and deliver community supports
services including housing community support services
Services Provider
•
referred by ACH
1 Effective January 1, 2024, the MCPs in Alameda County are Alameda Alliance for Health (AAH) and
Kaiser Permanente (Kaiser). Kaiser provides their own community supports.
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3. Who to Contact
Questions or concerns from HCS service providers should be directed by email to CalAIM@acgov.org;
ACH staff will respond within three business days.
For urgent requests, providers can call 510-567-8014.
B. Scope of Services
ACH administers the delivery of HCS for a broader population than consumers enrolled in Medi-Cal
managed care; however, ACH utilizes DHCS definitions as the basis for these types of services. Eligibility,
service definitions and service limitations for HCS are detailed in California Department of Health Care
Services (DHCS) guidance here: DHCS-Community-Supports-Policy-Guide (ca.gov). Contractors are
expected to review and understand the state policy guide.
Services defined under HCS include helping consumers find, move-into, and retain housing. A critical
component of maintaining housing is benefits advocacy and connecting consumers to other mainstream
services. Critical to the sustainability of this program, and to the health maintenance of consumers, is
enrollment and retention in Medi-Cal or other health insurance coverage. As such, contractors are
required to ensure that consumers apply for and retain Medi-Cal enrollment if eligible.
C. Requirements to Complete Prior to Contract Execution
Under each HCS contract, the provider agency is responsible for submitting documentation and
completing training (outlined below) to fulfill Medi-Cal managed care requirements.
The requirements described in this section reflect managed care requirements for Alameda Alliance for
Health (AAH).
1. Credentialing Requirements
Requirements for Organizations contracted with ACH to Provide Housing Community Supports
HCS organizations, both during initial onboarding as a ACH contractor and every three years thereafter,
are required to complete the provider credentialing process for Housing Community Supports by
choosing one of three pathways:
1. State-level Medi-Cal provider
2. Enhanced Care Management (ECM) provider
3. Housing Community Supports (HCS) provider
For organizations credentialed through either the state-level Medi-Cal Provider pathway, OR as a
provider of Enhanced Care Management (ECM), the requirement to be credentialed under Housing
Community Supports is to send a letter of attestation to ACH (calaim@acgov.org; Attn: Quality
Improvement & Training Coordinator) which confirms that the organization is, or will be
credentialed through the respective pathway. Organizations do NOT need to fill out further paperwork
to be credentialed as a HCS Provider with ACH.
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If the organization is not credentialed through either pathway #1 or #2 above, the organization must
complete the Credentialing Application Process with ACH (pathway #3):
1. Submit the following required documents to calaim@acgov.org; subject line: (Agency Name)
Alliance Credentialing Documents, Attn: Quality Improvement & Training Coordinator. Please
see Appendix 1 and 2 for copies of the application materials.
a. AAH Organization Provider Application (pages 3-5), completed, signed, and dated
b. Community Support and Enhanced Care Management Organization Attestation (page 6),
signed and dated
c. Copy of valid, current, and unrestricted state business license to operate in good
standing with no sanctions
Requirements for Staff Providing Housing Community Support Services at Contracted Agencies
It is a state requirement that licensed/certified provider staff administering services under Medi-Cal,
must be enrolled as a Medi-Cal provider through PAVE (Provider Application and Validation for
Enrollment, known as Medi-Cal Fee for Service). This includes any individual staff member or
organization who has a Medi-Cal enrollment pathway, AND who is within an organization funded
through a ACH Housing Community Supports contract (see this link for full list of provider types) which
includes staff providing direct services or supervision. The most likely positions funded through a ACH
HCS contract include licensed clinical social worker (LCSW) and/or licensed marriage and family therapist
(LMFT), however the agency is responsible for reviewing the provider type list. Staff needing to
complete the enrollment process can find the application through the DHCS website. Documentation of
enrollment may be required as part of an audit.
2. Agency Staffing Plan
The purpose of an agency staffing plan is to identify which positions and the number of staff that are
covered under the organization’s HCS contract. The Agency Staffing Plan must include:
• Number of slots projected for HN and TSS
• Number of full-time equivalent (FTE) budgeted to support Housing Navigation (HN) and Tenancy
Sustaining Services (TSS). FTE summary should include:
o position type
o number of positions currently filled
o agency plan and timeline for to fill vacancies
Please see Appendix 3 for an example Staffing Plan template.
Agency Staff Onboarding/Departures
HCS organizations are responsible for communicating updates on staffing changes to calaim@acgov.org.
At minimum, an updated HCS staff point of contact summary should be sent to ACH on a quarterly basis.
3. Agency Training Plan
Exhibit A: Terms of Services in the Housing Community Supports Contract indicates that the contractor is
responsible for providing community support services in a culturally and linguistically competent
manner. The purpose of the agency training plan is for each agency to describe how they will provide
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the required cultural competency, sensitivity, and diversity training to their staff members. Please see
Appendix 4 for an example Training Plan template.
D. Training Requirements
HCS organizations shall provide HCS services in a culturally and linguistically competent manner, and
shall provide its staff training on cultural competency, sensitivity, and diversity, as reflected in their
Agency Training Plan (above).
HCS staff will be required to attend service provider trainings offered by ACH, as they become available.
These trainings will include the following Community Supports topics:
A. Community Support Services Overview
B. Care Coordination and Care Transitions within Community Supports
C. Community Resources and Referrals
D. Special Populations
E. Social Determinants of Health
F. Motivational Interviewing
G. Trauma-Informed Care
H. Health Literacy Assessment
HCS organizations may, with approval from the Quality Improvement & Training Coordinator, substitute
other trainings that cover the above topics.
ACH-HCS staff partners with both Alameda County Healthcare for the Homeless and the Alameda
County Supportive Housing Learning Collaborative, and other entities where applicable, to offer
trainings covering these topics. The schedule varies and HSCA will notify providers as far in advance as
possible of any upcoming required trainings.
E. Program Guidelines
1. Eligibility
Contractor shall serve individuals referred by ACH through Coordinated Entry for HCS services. To be
eligible to receive HCS through ACH, a consumer must be:
• Living in Alameda County; AND
• Literally homeless (as defined in Section 91.5 of Title 24 of the Code of Federal Regulations), OR
formerly homeless
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Table 1. Housing Community Supports Eligibility Rules
Enrollment Eligibility Rules
Housing Transition
Navigation (HN)
•
• Consumer must currently be “literally homeless,” AND
• Consumer does not have a lease (or similar) with a move in date
assigned, AND
• Consumer must be enrolled in HN HMIS project prior to receiving
Housing Deposits (HD)
•
AND require HD services, AND
• Consumers must be enrolled in HD HMIS project prior to contractor
Tenancy Sustaining
Services (TSS)
•
• Assessed as likely to benefit from services in a housing program or at
a site approved for tenants to receive Housing Community Supports,
AND
• Consumer is housed OR has an identified move-in date, AND
• Consumer must be enrolled in TSS HMIS project prior to receiving
2. Housing Community Supports Referrals
All referrals for Housing Community Supports will come directly from ACH. If contractor receives HCS
referrals from other sources (such as another community-based organization), contractors shall notify
ACH by emailing calaim@acgov.org (include the source of the referral and the individual’s HMIS ID) prior
to ACH confirmation of enrollment. Only referrals received directly from or approved by ACH shall be
enrolled in HCS HMIS projects. Once enrolled, an additional referral is not needed when transitioning
consumers from one HCS HMIS project to another.
Contractors shall maintain open communication with the ACH Referral Coordinator regarding staff
capacity to support additional referrals; this is especially important during the ramp-up phase for new
contractors and when new HCS staff are onboarded. ACH will make best efforts to send referrals as
quickly as possible, usually within five business days, when notified by contractors of additional slot
capacity.
Once referrals are received, contractors shall conduct outreach to referred individuals in accordance
with the HCS Outreach Policy (see Appendix 15). Contractor shall accept and act upon referrals unless
contractor is at pre-determined capacity, and shall conduct outreach to the referred individual as soon
as possible, including making best efforts to conduct initial outreach within 24 hours of assignment.
Setting a pubic alert in HMIS, presenting the person at the relevant regional coordination meetings, and
a minimum of six outreach attempts using all available channels (documented as a note in HMIS) are the
basic required components of outreach. For additional details please see the HCS Outreach Policy.
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If all efforts to outreach to and enroll the referred individual have been exhausted in accordance with
the Outreach Policy without success, contractors shall notify ACH that they were unable to enroll and
the reason(s) for lack of enrollment.
Households that are (1) housed or have an identified move-in date; (2) have an unstable housing
situation (or are anticipated to have an unstable housing situation if not yet moved-in); (3) not currently
enrolled in HCS projects; and (4) have been assessed through Coordinated Entry, may be referred to
ACH for HCS-TSS services by service provider organizations using this form. ACH will assess these on a
case-by-case basis and refer the household for HCS services as contractor capacity allows.
Reverse Referrals
Goal:
Help consumers access services more quickly with providers they have existing connections with.
To shorten outreach times by connecting providers with consumers they have an existing relationship
with.
Policy:
HCS contractors will be able to refer eligible consumers directly for HCS-HN by sending an email with the
consumer HMIS ID and confirmation of eligibility to CalAIM@acgov.org. ACH will be assessing efficacy of
this project, gathering input from contractors, and will make adjustments as needed.
Referring Process:
Only HCS Program Managers can make an HCS HN reverse referral.
The referring party is responsible for screening for eligibility prior to the referral being sent.
For a consumer to be eligible, they must:
1. Be currently literally homeless AND on the housing queue
2. Not be enrolled in a duplicative program
3. Be currently served by or connected to the referring agency
4. The referring agency must have capacity to enroll and serve the referred individual
Approval Process:
Reverse referrals will be evaluated by ACH staff for the above eligibility criteria. If consumer does have
an existing pending referral, the pending existing referral will be cancelled and will be transitioned to the
requesting provider
Once ACH confirms eligibility, then the provider agency is notified to enroll the consumer in HN.
ACH will approve or deny request within five business days.
Access Point Referrals
Consumers will be referred by ACH following their prioritization. Best efforts will be made to refer
consumers to the provider Housing Resource Center (HRC) where they completed their Coordinated
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Entry assessment. However, some HRCs may be asked to serve consumers that did not complete their
Coordinated Entry assessments at that HRC.
When a consumer is successfully housed through Access Point Housing Navigation:
a) Transfer the consumer internally to a case worker who serves consumers in TSS; or
b) Refer the consumer back to ACH for TSS and continue to support the consumer until they
are assigned with another agency, and complete a warm handoff once reassigned; or
c) Facilitate a warm handoff to location with site-based services.
Some consumers assessed by Access Points may be served in Housing Navigation through non-access
point HCS providers depending on project availability to serve the general needs of the actively
homeless population.
Consumer Reassignment
Alameda County Health (ACH) reserves the right to reassign any consumer from an HCS subcontracted
provider to another subcontractor if deemed necessary. This is reserved only for extreme circumstances
where ACH believes a consumer is not receiving the necessary services to either sustain (TSS) or obtain
(HN) housing. While not limited to the following, please see the listed factors that could lead to
reassignment:
1. A consumer has been without services for a significant period of time despite showing high
needs
2. A provider organization is unable to complete required paperwork justifying the consumer’s
enrollment (housing support plans, TSS extension requests, voucher recertification paperwork)
3. Systematic understaffing that contributes to a consistent lack of services for consumers
While ultimately reassigning consumers is up to the discretion of the ACH HCS team, no consumer will
be reassigned without consultation and problem solving with the current provider organization. There
are multiple factors that the ACH HCS team will consider before reassigning a consumer including but
not limited to:
1. The consumer’s enrollment in PSH
2. The subcontracted agency’s plan to resolve the issues noted by the ACH HCS team
Subcontracted organizations will be notified via email if a consumer needs to be reassigned and a
meeting will be scheduled to discuss next steps within five business days. That meeting will also reflect
the last opportunity to request that the consumer remain with the existing organization and any
proposed plans for retention will be considered by ACH staff.
Additionally, subcontracted HCS providers may request a consumer be reassigned from their caseloads.
These will be considered on a case-by-case basis and are reserved only for circumstances where
reassignment is the last option for consumer success. Reassignment requests can be emailed to
CalAIM@acgov.org for the following reasons:
1. Consumer behavioral issues are causing safety concerns for existing staff
2. Systematic understaffing that contributes to a consistent lack of services for consumers
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3. If a provider agency only serves consumers in navigation and needs to reassign a consumer after
they are housed.
In all cases, once a consumer has been reassigned to a new subcontractor, ACH HCS will set up a warm
handoff meeting with the former and new HCS subcontractors to discuss the warm handoff process for
the consumer.
3. Enrollment in Housing Community Supports
To ‘enroll’ a consumer referred by ACH for HCS services, enter the consumer into the relevant HCS HMIS
Project AFTER a consumer has been contacted, has verbally agreed to engage in services, and HMIS
intake information has been collected. Additionally, prior to enrollment, contractors should verify that
the consumer is not already actively enrolled in HCS with another contractor. If they are, contractors
should notify ACH and request guidance instead of completing the enrollment at that time. Exceptions
to this guideline exist, such as situations when a site-based contractor is enrolling someone in TSS and
the consumer is still enrolled in HN with a different contractor.
Only the head of household (the referred individual) should be enrolled into HCS projects (ie do NOT
activate toggles for linked household members during project enrollment).
Re-enrollment in Housing Community Supports
Before enrolling a consumer in TSS or HD, check their program enrollment history to determine whether
or not this is their first time receiving TSS or HD services.
In situations where a consumer has been previously enrolled in and exited from HCS, but a need for
services arises again at a later time, re-enrollment may be approved by ACH on a case-by-case basis.
After an initial enrollment, Housing Deposits and Tenancy and Sustaining Services can only be approved
one additional time provided documentation is submitted detailing what conditions have changed to
demonstrate why providing the service would be more successful on the second attempt. To request a
2nd enrollment into TSS of HD, complete this form. ACH will review the request and follow up with
contractors by email within 10 business days. Supporting documentation is not required for a 2nd
enrollment in Housing Navigation. Failure to submit requests and obtain approval for second TSS or HD
enrollments will result in payment being withheld for services.
4. Service Requirements
HCS services begin ONLY AFTER the referred consumer has been contacted and has provided verbal
consent to engage in services. All consumers must have an individualized Housing Support Plan
identifying the need for the Housing Community Support services (completed within 15 days of HCS
enrollment and uploaded to HMIS within 30 days of enrollment).
Housing Navigation Transition Services assist households with obtaining housing and include (list will be
updated in next provider manual version to reflect updated state policy guide service definitions):
1. Conducting a tenant screening and housing assessment that identifies the Household’s
preferences and barriers related to successful tenancy. The assessment may include collecting
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information on the Household’s housing needs and on potential housing transition barriers, as
well as identification of housing retention barriers.
2. Developing an individualized housing support plan based upon the housing assessment that
addresses identified barriers, includes short- and long-term measurable goals for each issue,
establishes the Household’s approach to meeting the goal, and identifies when other Providers
or services, both reimbursed and not reimbursed by Medi-Cal, may be required to meet the
goal.
3. 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 eligibility and supporting the SSI application
process. Such service can be subcontracted out to retain needed specialized skill set.
6. Identifying and securing available resources to assist with subsidizing rent (such as U.S.
Department of Housing and Urban Development’s Housing Choice Voucher Program (Section 8)
or state and local assistance programs) and matching available rental subsidy resources to
Consumers.
7. Identifying and securing resources to cover expenses, such as security deposit, moving costs,
adaptive aids, environmental modifications, and other one-time expenses.2
8. Assisting with requests for reasonable accommodation, if necessary.
9. Educating and engaging with landlords.
10. Ensuring that the living environment is safe and ready for move-in.
11. Communicating and advocating on behalf of the Consumers with landlords.
12. Assisting with 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, nonmedical transportation to
assist Consumers’ mobility to ensure reasonable accommodations and access to housing options
prior to transition and on move-in day.
15. Identifying and coordinating environmental modifications to install necessary accommodations
for accessibility (see Environmental Accessibility Adaptations Community Support Services).
16. Ensuring that HCS staff take the required components of the Coordinated Entry System (CES)
training at training.bitfocus.com/page/alameda within 30 days of hire. Currently, this includes
the Coordinated Entry Specialist Training Series.
17. HCS staff shall
a. maintain consumers' CES entries in HMIS;
b. complete a Current Living Situation Assessment for each consumer once per calendar
month or when their circumstances change;
c. update CE Housing Assessments every six months and Crisis Assessments every 90 days,
or when there is a significant change;
d. coordinate with a CE Access Point to exit consumers from coordinated entry when
housed or if they move out of the County; and
2 Actual payment of these housing deposits and move-in expenses is a separate Community Support
under Housing Deposits.
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e. coordinate with a CE Access Point to exit consumers from the housing queue if
approved by the HCS Referrals Coordinator.
All Housing Navigation staff, and especially those hired as part of Street Health/Access Point expansions,
are expected to attend, and actively participate in, Alameda County Regional Coordination meetings for
the region in which their work focuses. Please see the Outreach Policy (Appendix 15) for instructions
regarding requesting invitations to Regional Coordination meetings.
The services provided should be based on individualized assessment of needs and documented in the
individualized housing support plan. Households may require and access only a subset of the services
listed above.
The services provided should utilize best practices for Households who are experiencing homelessness
and who have complex health, disability, and/or behavioral health conditions. Examples of best
practices include Housing First, Harm Reduction, Progressive Engagement, Motivational Interviewing,
and Trauma-Informed Care.
The services may involve additional coordination with other entities to ensure the individual has access
to supports needed for successful tenancy. These entities may include County Health, Public Health,
Substance Use, Mental Health, and Social Services Departments; County and City Housing Authorities;
Continuums of Care and Coordinated Entry System; Sheriff’s Department and Probation Officers, as
applicable and to the extent possible; local legal service programs; community-based organizations;
housing Providers; local housing agencies; and housing development agencies. For Consumers who will
need rental subsidy support to secure permanent housing, the services will require close coordination
with local Coordinated Entry Systems, homeless services authorities, public housing authorities, and
other operators of local rental subsidies. Some housing assistance (including recovery residences and
emergency assistance or rental subsidies for Full-Service Partnership Consumers) is also funded by
county behavioral health agencies. When appropriate, contracted Community Support Providers should
expect to coordinate access to these housing resources through county behavioral health.
Restrictions and Limitations
Housing Transition/Navigation Services must be identified as reasonable and necessary in the
individual’s individualized housing support plan. Services duration will need justification in the housing
support plan if needed for longer than 12 months. The housing support plan should include an
explanation as to why the consumer was not housed after 12 months and a plan to address the reasons
the consumer was not housed.
Individuals may not be receiving duplicative support from other State or local tax or federally funded
programs, which should always be considered first.
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Housing Tenancy and Sustaining Services
The goal of tenancy and sustaining services is to maintain safe and stable tenancy once housing is
secured. Services include (list will be updated in next provider manual version to reflect updated state
policy guide service definitions:
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. Education and training on the roles, rights, and responsibilities of the tenant and landlord.
3. Coaching on developing and maintaining key relationships with landlords/property managers
with a goal of fostering successful tenancy.
4. Coordination with the landlord and case management Provider to address identified issues that
could impact housing stability.
5. 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 Consumer owes back rent or payment for damage to the unit.
6. Advocacy and linkage with community resources to prevent eviction when housing is or may
potentially become jeopardized.
7. 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 needed specialized skill set.
8. Assistance with the annual housing recertification process.
9. 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.
10. Continuing assistance with lease compliance, including ongoing support with activities related to
household management.
11. Health and safety visits, including unit habitability inspections.3
12. 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).
13. Providing independent living and life skills, including assistance with and training on budgeting,
including financial literacy and connection to community resources.
The services provided shall be based on individualized assessment of needs and documented in the
individualized housing support plan. Individuals may require and access only a subset of the services
listed above.
The services provided shall utilize best practices for consumers who are experiencing homelessness and
who have complex health, disability, and/or behavioral health conditions including Housing First, Harm
Reduction, Progressive Engagement, Motivational Interviewing, and Trauma-Informed Care.
The services may involve coordination with other entities to ensure the individual has access to supports
needed to maintain successful tenancy.
3 Does not include housing quality inspections.
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Services do not include the provision of room and board or payment of rental costs.
While transitioning between housing transition navigation services and housing tenancy and sustaining
services, consumers may receive both services simultaneously for up to 30 days.
Restrictions/Limitations
These services are available from the initiation of services through the time when the individual’s
housing support plan determines they are no longer needed. They are only available for a single
duration in the individual’s lifetime. Housing Tenancy and Sustaining Services can be approved one
additional time with documentation as to what conditions have changed to demonstrate why providing
Housing Tenancy and Sustaining Services would be more successful on the second attempt.
Contractors are required to complete a “Housing Community Supports TSS Evaluation” assessment for
each consumer after one year of services, and every 180 days, thereafter. TSS Evaluations serve to
assess whether services are still necessary and provide a mechanism for contractors to justify that need.
The Evaluation How-To guide can be found in Appendix 14. Failure to submit TSS Extension Assessments
prior to the final due date will result in payment being withheld for services (See Appendix 17).
Additional trainings and resources on this topic are available on the Housing Community Supports web
page. NOTE: the “TSS Evaluation” will be integrated into a new HMIS assessment-based Housing Support
Plan (ie no longer separate documents), with anticipated launch in June 2025.
These services must be identified as reasonable and necessary in the individual’s individualized housing
support plan and are available only when the consumer is unable to successfully maintain longer-term
housing without such assistance.
Consumers may not be receiving duplicative support from other State, local, or federally funded
programs, which should always be considered first.
Contractors are responsible for documenting a consumer’s verbal consent to receive HCS services, for
each type of Housing Community Supports offered. Please see Appendix 5 for guidance on acceptable
ways to document verbal consent. Consumers’ verbal consent will be verified during quarterly audits
(see section F.1.).
Billable Encounters
For consumers enrolled in Housing Navigation and Tenancy Sustaining services, a billable service is
• An instance of direct Provider-to-Consumer interaction (either in-person or via phone/other
technology) during which HN/TSS services occurred
These services should be entered into HMIS as:
Service Category: Case Management
Type of Service: Individual Meeting
In order to the paid the monthly PMPM rate for a given consumer:
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1. at least one service in a given month must fall under the “billable service” guidelines above;
AND
2. That service must be logged as Case Management + Individual Meeting in HMIS, AND
3. The consumer must have an updated HSP (within 30 days of enrollment and updated every 180
days)
Other Services
For consumers enrolled Housing Navigation and Tenancy Sustaining services, the following are not
considered billable HN/TSS encounters. However, these ARE services that are covered as part of the
PMPM rate and should be logged in HMIS under the most appropriate Service Category/Type of Service.
• Outreach attempts (after enrollment) that do not result in successful contact
• HN/TSS services encounter follow-up activities, without the consumer present, such as housing
research, coordinating with landlords or other service providers, submitting referrals for other
supports/resources, etc.
Example Scenario 1: The only services provided during the month are:
1. Service provider submits a referral for Enhanced Care Management on behalf of a consumer and
enters this service in HMIS under “Health Care” “Referral” service category
2. Service provider calls the consumer to update them on the referral but is not able to connect.
Being unsuccessful telephonic outreach, this is not entered as a service.
In this scenario the Contractor is not paid the PMPM rate for the month because there is not a
billable encounter.
Example Scenario 2: The only services provided during the month are:
1. Service provider has a meeting with the consumer’s landlord (without the consumer present) to
discuss a pending unit repair that has been delayed. Service provider enters this service in HMIS
under “Housing” “Problem Solving” service category.
2. The service provider meets with the consumer to update them on the meeting and the status of
the unit repair timeline and enters this billable encounter under “Case Management
Individual Meeting” service category.
In this scenario the Contractor is paid the $620 PMPM for the month
Please see Appendix 18 for detailed guidance on billable encounters and how they must be entered into
HMIS.
Activities Not Considered Services
The following are examples of activities and situations that are not considered billable encounters or
other services. Instead of being logged as services, all of the below should be logged as a “note” in HMIS.
• Outreach to consumers prior to obtaining consent and enrolling in Housing Navigation and
Tenancy Sustaining services.
o Note: As of July 1, 2024, pre-enrollment outreach is billable, but is separate and distinct
from PMPM reimbursement. See Appendix 18 for details.
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• A consumer or administrative update that does not involve activities performed by the case
manager. Examples:
o “Consumer stopped by the office to pick up their mail”
o “Consumer attended weekly coffee social in the community room”
o “Received a text from consumer stating their furniture had been delivered”
o “Consumer submitted an updated verification of income to the case manager”
• Phone calls/texts reporting to the consumer that the case manager has no updates for them
Contractor will follow consumer/staff caseload ratios of no more than 25:1 active consumers for HN
services and an average of 25:1 for TSS.
Service providers are expected to maintain frequent contact with consumers including home visits,
phone calls, and face to face visits in the community. Regular contact with consumers is important to
ensure they have all documentation, are connected to services that support housing stability such as
income (SSI/GA/employment), active health insurance, and there is an active housing search that
includes connections to family, shared living and following up with housing matches as available. For
newly, or soon-to-be housed TSS consumers, more frequent contacts and weekly face to face visits may
be needed to support the often-stressful transition from unhoused to housed locations until the
consumer is stable in their housing. All services must be delivered with a commitment to Housing First
principles, including non-judgmental compassion, harm reduction, and respect for consumer choice,
with the goal of helping consumers get and keep housing and avoid returning to homelessness.
Service providers are expected to establish and maintain regular communications and trusting
relationships with consumers in order to do the following:
• Develop an individualized Housing Support Plan in consultation with consumer based on their
strengths, hopes and needs.
• Document all services provided to the consumer in HMIS.
• Provide ongoing support and coordination in the following areas, as needed:
o Getting and keeping public benefits for which consumers are eligible, including income /
financial assistance and health insurance coverage
o Assistance with connecting consumers with representative payee services
o Access to and coordination of health and behavioral health services, including peer
support for recovery and wellness
o Identifying and reducing barriers to housing stability, including increasing motivation
and providing support to reduce risks or harms related to substance use
o Life skills including managing a budget and household
o Employment / education
o Community building / engagement in meaningful activities
o Building and expanding social connections including non-professional networks and
supports
• Provide problem-solving support to the consumer and coordinate with the Rental Assistance
and Landlord Engagement (RALE) Program (if applicable) to facilitate effective communication
and mediate disputes with property owners or managers. HCS staff should check HMIS for RALE
enrollment when beginning services for consumers at scattered sites. This coordination should
include, at a minimum, monthly check-ins with the RALE program staff or directly with the
property owner / manager (every two months) to get updates on the status of tenancy. This
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coordination and communication should be more frequent as necessary to address problems
and help the tenancy sustaining services consumer to avoid eviction. HCS staff should not exit
consumers from services without discussing with RALE staff, and should consult with RALE staff
when developing and updating Housing Support Plans and TSS extensions.
HCS consumers linked to RALE will have an open HMIS enrollment in one of the following
projects:
Or, anything that says “RALE” in the project stamp, for example:
5. Housing Deposits
Service providers may provide Housing Deposits for consumers who are receiving HN or TSS services.
The HCS-HN/TSS enrollment in HMIS must remain open while HD funds are being used. HMIS enrollment
and service entry/expense documentation must be inputted in the separate HD HMIS project. HD
project enrollment and exit dates should correspond with date of first and last purchase, respectively,
which should happen within a six-month timeframe. Contractor can spend up to $5,000 per consumer,
expenses must be entered into HMIS and backup documentation must be saved and available for review
during quarterly audits.
Housing Deposits expenses must be tied to a move-in and assist with identifying, coordinating, securing,
or funding one-time services and modifications necessary to enable a person to establish a basic
household that do NOT constitute room and board, such as
• Housing application fees
• Security deposits required to obtain a lease on an apartment or home
• Set-up fees/deposits for utilities or service access and payment in utility arrears
• First month coverage of utilities, including but not limited to telephone, gas, electricity, heating,
and water
• Furniture and household items that assist with establishing a household
• 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
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• Set up fees for renter’s insurance
• Expenses related to obtaining core documents required for applying to or securing housing
• 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.
As of September 1, 2025, first and/or last month’s rent is not an eligible service under Housing
Deposits.
Other one-time expenses related to a move-in may be considered allowable on a case-by-case basis.
Please email calaim@acgov.org for guidance when questions arise.
The items purchased must be identified as reasonable and necessary in the consumers’ individualized
housing support plan and are available only when the consumer is unable to meet such an expense.
Housing Deposit Refunds and Corrections
If an item that has been purchased for a consumer is later returned with the refund received, or if a
Housing Deposit expense was entered with an incorrect amount and needs to be edited, contractors
should follow these steps:
1. Edit the service encounter in HMIS:
a. Access the service in the History tab of the program and select option to edit (click on
the pencil icon)
b. If there was a full refund, under the expense section select the trash can icon next to the
returned expense amount
c. If partial refund, select the edit icon next to the expense and edit the amount in the
popup window to reflect the original amount minus the refund. This same procedure
can be used for editing an HD expense amount outside of a refund situation, such as
when the originally entered amount was incorrect.
d. Provide detailed notes in the notes section (of the HD service entry) including original
expense amount and dates paid out, refund amount, date refund was received, and
reason for return
2. If this change is made BEFORE the 3rd day of the month following the purchase (for example if
the purchase was made on February 16th and the return was made prior to March 3rd), then this
service will appear on that month’s invoice as a $0 claim, or will accurately reflect the updated
expense summary
2. If the return or correction is made AFTER the 3rd day of the month following the purchase, then
follow the same process for editing the expense outlined in (a) through (d) above AND email
ACH at calaim@acgov.org with the following information:
a. HMIS ID of the consumer
b. Date and amount of the original expense
c. Date and amount of the refund
d. Date the original expense amount was corrected in HMIS
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3. ACH staff will track these post-3rd of the month corrections and manually deduct them from the
following month’s invoice
If a submitted Housing Deposit expense has been denied and deemed ineligible by ACH, contractor
must delete the service by following these steps:
1. Access the service in the History tab of the program and select option to edit (click on the pencil
icon)
2. Scroll down until you see the “Programs” section. Hover over the program name (“AGENCY-CAF-
SSO-HCS-HD-HCSA-HHAP”), and you will see a trash icon appear. Select the trash icon and then
“OK” when the popup asks for confirmation. This will delete the service and it will no longer
appear in the History tab
3. Add a note in the “Notes” tab within the program detailing the deleted service
If ACH discovers a consumer has exceeded their $5,000 Housing Deposits limit, ACH will send
guidance to edit the most recent HD service entry such that the total expended reflects $5,000. For
example, if a $500 furniture purchase puts the total expenses incurred at $5,050, ACH will alert the
contractor and instruct them to edit the service entry (follow steps (a) – (c) above) to reflect an
expense amount of $450.
6. Housing Support Plan
A completed Housing Support Plan (HSP) is required for all consumers enrolled in HCS services. HSP’s
must be completed within 15 days of enrollment, and must be uploaded into HMIS within 30 days of
enrollment. Failure to complete an HSP for a consumer will result in payment for services being
withheld. Agencies may use their own template; see Appendix 8 for an optional template.
HSP’s must be reviewed and updated as needed every 180 days. The 180-day reviews must be uploaded
to HMIS at least 15 days before they expire. For example, if a HSP is developed on January 1, the 180-
day review must be uploaded to HMIS no later than June 15.
HSP’s must demonstrate ongoing need for services. For HN consumers that need to continue services
for longer than 12 months, an updated HSP shall include an explanation as to why the consumer was
not housed after 12 months and a plan to address the reasons the consumer was not housed.
For TSS consumers, Contractor shall also complete a “TSS Evaluation” assessment in HMIS at each HSP
update. (Note: the initial HSP does not require a TSS Assessment.) For consumers that are
recommended to continue TSS services, the TSS Evaluation should include specific, measurable, time-
related goals toward graduation. NOTE: the “TSS Evaluation” will be integrated into a new HMIS
assessment-based Housing Support Plan (ie no longer separate documents), with anticipated launch in
June 2025.
If a consumer does not have a new HSP uploaded into HMIS within 30 days of enrollment or an update
every 180 days thereafter that demonstrates ongoing need for services, County will follow up with the
Contractor in writing and withhold payment for services. If the HSP is not up to date within 30 days of
written follow-up, County may re-assign the consumer to another provider. Failure to comply with
deadlines may result in a formal Corrective Action Plan.
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7. Housing Community Supports Project Exits
An HCS project exit may happen under the following circumstances:
• Consumer has been lost to services (no service encounter for 90 days) despite repeated,
assertive efforts by the service provider to contact and engage with the consumer in accordance
with the outreach guidelines of the Outreach Policy (See Appendix 15), including attempts to
meet with the consumer in person by visiting their home or other community settings where
they are likely to be found, communication with the consumer’s designated emergency contacts
or other service providers (including assigned RALE staff, if applicable), and the use of available
data (including HMIS or Community Health Record) to determine whether the consumer is
hospitalized, incarcerated, or in a treatment facility; OR
• Consumer no longer requires services per their Housing Support Plan and/or TSS Evaluation, OR
• Consumer has made a clear request (verbally or in writing) to be exited from HCS services., OR
• Consumer is being served in a duplicative program by another agency.
For consumers enrolled in the Rental Assistance and Landlord Engagement (RALE) program, contactors
are expected to collaboratively discuss plans for HCS exits (for any reason) with assigned RALE staff prior
to exiting consumers. Other service providers that are connected to the consumer (mental health
providers, etc.) should be engaged in the decision to graduate consumers from HCS services.
In addition, consumers in Housing Navigation should be exited from Housing Navigation and enrolled in
Tenancy Sustaining Services (or other comparable services) within 30 days after they have moved into
housing. If a consumer is transitioning from one case manager to another as part of the transition,
whether transitioning within the same organization or to another organization, the consumer can
continue to receive Housing Navigation services for 30 days past move-in date to complete the move-in
process and facilitate care coordination and transition to support from another organization. Consumers
should remain in housing navigation until after they have moved in and completed any needed
purchases with housing deposit funds.
Consumers must be disenrolled from Housing Deposits within six months of the enrollment date. If
additional time is needed, providers must email calaim@acgov.org with a brief explanation of the need
for an extension.
The reason for HCS TSS or HN project exit shall be documented as a note in the “Notes” tab within the
project listing, noting that is not required if the reason for exit is that they are transitioning to another
HCS project (HN TSS for example).
Contractors are expected to follow the HMIS Exit Destination guidelines outlined in this guidance.
In all cases, prior to HMIS project exit, the HCS provider must attempt to facilitate connections to other
supportive services in the community that can be responsive to the consumer’s needs and preferences
and support their individual goals related to housing stability, safety, and recovery. For all consumers
who are living in a supportive housing program, including scattered site supportive housing with tenant-
based rent subsidies, the HCS provider must notify the housing program or housing subsidy provider at
least 30 days prior to exiting a consumer from services.
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8. HMIS Guidelines and Requirements
Contractor shall provide real-time (not to exceed three business days after the date of service) HMIS
data entry for all consumers served. At a minimum, this will include the consumer profile, program
enrollment (intake), Current Living Situation updates, Coordinated Entry updates (see #17 under
“Service Requirements on 11), annual assessment, program exit, and documentation of all services
provided, as applicable. All staff providing HCS services shall input their name and contact information in
HMIS using the Contact tab and selecting “Housing Navigator/Case Manager/Care Coordinator” as the
“contact type”. For all consumers enrolled in TSS, the consumer’s home address must be added to the
Location tab in HMIS.
Current Living Situation
Current Living Situation (assessment) is required to be inputted regularly and updated within three
business days if there is any change in housing status. For a screenshot and details about entering
Current Living Situation, see this resource: Living Situation Updates for End Users.pdf (achmis.org).
9. Coordination with other Service Providers
Some consumers may be eligible to receive supportive services from more than one organization or
provider, provided these additional services are not duplicative HN/TSS services. When this happens,
service providers are expected to communicate with one another and with their consumers to be sure
everyone understands one another’s roles and responsibilities.
If a consumer who is receiving HN or TSS changes providers, it is the service provider’s responsibility to
provide timely notification to other case managers and the RALE program (if applicable) and/or to the
housing program (site-based supportive housing or subsidy provider for scattered site supportive
housing) regarding this change at least 30 days in advance of transitioning services. HCS staff should
email calaim@acgov.org if encountering delays or assistance is needed in contacting another
organization’s HCS staff member.
Contractor shall coordinate with other providers on the consumer’s care team, including ECM Providers,
other Community Support providers, other service providers, ACH, and health plans.
Contractor shall coordinate referral and outcome of referral to Enhanced Care Management (ECM)
Provider for consumers enrolled in ECM.
Warm Handoffs
Consumers transitioning from one HCS service provider to another is a common occurrence in Housing
Community Supports. Ensuring these transitions are timely and as seamless as possible is the
responsibility of both the existing and new provider. To support this, ACH allows a 30-day overlap period
during which both providers may bill for services. Warm handoffs may be needed under a few different
scenarios, but the three most common are:
1) Consumer moves into a site-based location with on-site TSS. In these cases, the new TSS
provider should outreach to the existing provider to initiate the warm handoff and coordinate a
transition plan.
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2) Consumer moves out of the geographic region the existing provider serves. In these cases, the
existing provider should reach out to calaim@acgov.org to request re-assignment and continue
to serve the consumer until a warm handoff connection can be made
3) Consumer is linked to HN via the Access Point expansion and transitions to TSS. In these cases,
the primary goal is to hand off the consumer internally to a TSS team within the existing
provider organization. If that is not feasible, the existing provider should reach out to
calaim@acgov.org to request re-assignment and continue to serve the consumer until a warm
handoff connection can be made.
To be successful in warm handoffs, the following are needed:
1) Up to date provider contact information in HMIS Contacts tab
2) Up to date and detailed Housing Support Plan that the new provider can reference and build off
3) Double checking current project enrollments before enrolling a consumer into services
4) Proactive, early communication, especially prior to move-ins
5) An open dialogue with calaim@acgov.org around barriers and hurdles
During warm handoffs between an HN and TSS provider, it is also important to coordinate and maintain
open communication around which provider is supporting with Housing Deposit services to avoid
duplication. In general, the HN provider is responsible for providing Housing Deposit services. However,
in cases where HD services need to extend beyond the allowable 30-day overlap period, HD services can
be passed off to the TSS provider to complete move-in expenses. In these cases, the TSS provider would
need to complete HD services within 6 months of the initial HD enrollment.
10. Documentation
The following items must be documented by Contractors and available upon request:
• Documented outreach to consumers in accordance with the Outreach Policy (see Appendix 15
for guidelines)
• Confirmation of verbal consent obtained (see Appendix 5 for guidelines)
• Individual Housing Support Plan (see Appendix 8 for guidelines) and TSS Evaluation, if applicable,
(see Appendix 14 for guidelines)
• Receipts and proof of payment for housing deposit funding assistance
F. Reporting, Quality Assurance, and Quality Improvement
1. Audit Protocol
Housing Community Supports project audits will be conducted quarterly to review program compliance.
ACH will select a random sample of five percent of consumers receiving HN/TSS services and 15% of
consumers receiving HD services in HCS HMIS projects during applicable quarters to be subject to
auditing. Audits will be comprehensive and will include the following:
1. Review of housing deposit receipts (which should match what has been entered into HMIS) and
confirmation that HD expenses for each selected consumer does not exceed $5,000.
a. Accompanying documentation demonstrating need for housing deposit assistance
2. Review of individual housing support plans
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a. Verification that support plans include the minimum required elements and reflect
accompanying HCS need (i.e. amended plans if multiple project enrollments)
b. Verification that requested Housing Support Plans are dated within180-daysof the date
of submittal to ACH and are uploaded into HMIS as required.
3. Review of overall percentage of contractors’ enrolled consumers who have an up to date
Housing Support Plan
4. Review of consumer verbal consent documentation and dates
5. ACH Required Trainings: Dates and documentation of training provided to HCS staff covering
HCS required trainings, including any new staff onboarded during the quarter
6. Agency Capacity: Direct Service Full-Time Equivalent (FTE) compared to the caseload to verify
standard met:
a. No more than 25:1 for HN
b. An average of 25:1 for TSS
7. Additional accompanying documentation may be requested, as needed
Audit reports and all documentation must be submitted to sharefile on or before the due date each
quarter.
Based on audit results, ACH administration will develop a report with key findings that will be used to
provide technical assistance and may impact retroactive funding reimbursement needs or future funding
for the contractor. Please see Appendix 7 for more detailed information on HCS audits.
2. Quality Measurement and Improvement
ACH performs routine monitoring of program activities to ensure compliance with established policies
and procedures and high program integrity. These activities are described below.
Frequency Program Area Activity
Monthly
Housing
Community
Support Slot
Contractor is responsible for reporting updated FTE by e-mail to
ACH (calaim@acgov.org) monthly. This can be done by replying to
the monthly data quality reports
Monthly HMIS Data Quality
Auditing
items, that may require contractor updates and action:
• Medi-Cal enrollment and renewals
• Current Living Situation Status
• HD enrollments approaching six months
• Consumers lacking Housing Support Plans
• Consumers with no services entered within past 60 days
• Overlapping enrollments in HN and TSS/dual enrollments
with other contractors
• Consumers on the Housing Queue with inactive
Coordinated Entry
• Confirmation of enrollment of referrals
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•
period, billable encounters and non-billable services are
Quarterly
Contractor
Reporting and
Audits
quarterly reports on the 30thth of the month following the end of
the quarter using the Contractor Dashboard template. See
3. Grievances
Consumer grievances, considered here as any written expression of program dissatisfaction, shall be
addressed by contractors according to their internal grievance policies and procedures, as outlined in
the H&H-HCS Grievance Policy (see Appendix 16) Contractors must share their grievance policy with
consumers during the intake process, have it available upon request during service duration period, and
should make their policy easily accessible. Contractors must forward all grievances from consumers
pertaining to services described in the HCS contract that are not resolved by the contractor immediately
to ACH. For additional details please refer to the Grievance Policy.
G. Data, Invoicing, and Payment Guidelines
1. Services-As-Needed Contracts
HMIS Data Entry and Payment
All payments for Housing Community Supports (HCS) services will be based on complete and accurate
data entered into HMIS.
Housing
Community
Housing Transition
Navigation Services
(HN)
PMPM
approved consumer who:
1)Has an active enrollment in the HN Project, and
2)Has at least one direct contact during the reporting
month*
3) Has an uploaded Housing Support Plan w/in 30 days of
Housing Tenancy
Sustaining Services
(TSS)
PMPM
approved consumer who:
1) Has an active enrollment in the TSS Project, and
2) Has at least one direct contact during the reporting
month*3) Has an uploaded Housing Support Plan w/in 30
days of enrollment. HSP must not be older than 180 days*
4) Has a completed TSS Evaluation, as needed (see
Housing Deposits
(HD)
Cost-based
reimbursement Project (max of $5,000 per consumer).
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Outreach attempt, length of
time dependent
consumer who:
1) Has a pre-enrollment outreach attempt (minimum of 8
minutes long) at a rate of
a. 8-22 min ($10)
b. 23-37 min ($20)
*denotes new requirement effective 3/1/25
HCS Services-As-Needed Agreement, Exhibit A, Terms of Service, item #11: Service encounter should be
entered into HMIS on the date of service (not to exceed three business days from the date of service).
Invoicing
• Contractors must submit a monthly Services-As-Needed invoice for the HCS program.
• Contractor will send an invoice based on “allowable claims.”
• “Allowable claims” are based on data entered into HMIS.
• ACH will provide Contractor with an “allowable claims” report via Sharefile each month that
includes Housing Transition Navigation Services, Housing Tenancy Sustaining Services, Housing
Deposits, and pre-enrollment outreach.
• Contractor will submit a single invoice, based on “Allowable Claims” for HN, TSS and HD, and
pre-enrollment outreach
• Monthly invoices should include all components referenced in the transmittal letter.
• Monthly invoices should include the following attachments:
o Provider Report Encounters Summary and Details tabs with the first name, last name,
and date of birth columns hidden
o Provider Report Claims Summary and Details tabs with the first name, last name, and
date of birth columns hidden
o Provider Report Pre-Enrollment Outreach Summary and Details tabs with the first
name, last name, and date of birth columns hidden
• Monthly invoices should be submitted to HH.contracts@acgov.org and should CC
CalAIM@acgov.org. The email Subject Line should read “[Contractor Agency] HCS SAN Invoice
[Month] [YEAR].”
On the 11th of each month (or next business day), contractors will receive via Sharefile:
1) A summary of allowable claims (including outreach) that can be included in that month’s invoice
(based on data in HMIS through the 3rd day of the month following the billing month), and
2) Detail on consumers and services included.
If a Contractor finds any services encounter data that was missing, Contractor has 30 days to fix the
services encounter HMIS data (payment will be captured in the following month’s “allowable claims”).
Example: January data must be entered by February 3. If contractor finds missing data, it can be added
to HMIS by March 3 to be included in the February invoice. See chart below for date ranges.
Contractors are strongly encouraged to:
1) Maintain real-time data entry in HMIS including enrollment, exit and all service encounters
2) Conduct internal quality assurance checks to ensure that data is being entered in HMIS
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3) Complete ALL data entry for the service month by the end of the day on the 3rd day of the
following month.
*This includes service month and any added data from previous service month.
Service Month Date Data Should be
Complete in HMIS*
Date Range Included ACH provides
“Allowable Claims”
January
February
March
April
May
June
July
August
September
October
November
December
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H. Appendices
1. Alliance Organization Provider Application (pages 3-5)
28
29
30
2. Community Support and ECM Organization Attestation (page 6)
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3. Staffing Plan Template
AGENCY STAFFING PLAN
<AGENCY NAME>
Please list every position in your organization that will be covered under the FY[YEAR] contract. The first row provides an example of the information to be collected.
Point of Contact: NAME, TITLE
Email Address:
Job Title Job Description # of Current # of Anticipated
FY[YEAR]
Example) Housing Navigator, Supervisor, Case
Collaborates with service providers and provides general housing support to ensure that homeless individuals and/or families can secure and
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4. Staff Training Plan Template
Instructions: Please explain how your organization will provide the required training of cultural
competency, sensitivity, and diversity to the community support staff members. Please include any
relevant information such as frequency of training, upcoming dates, and the positions required to
attend.
Agency Name:
Point of Contact: Email Address:
Name of Organization:
Narrative of Training Plan:
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5. Verbal Consent Guidelines
Purpose
All consumers newly referred for Housing Community Support (HCS) Services are required to provide
verbal consent to services prior to their enrollment in the program. Consumers who have a
grandfathered enrollment from Heath, Housing, and Integrated Services program to an HCS program do
not need to have verbal consent re-documented.
Documentation of verbal consent to receive HCS services is subject to review and confirmation during
HCS quarterly audits. Alameda County Health (ACH) may also request verbal consent confirmation for
demonstration to Managed Care Plan (MCP) requests.
Verbal Consent Documentation
Acceptable Documents
Agencies may utilize the following items below to document verbal consent for HCS services:
Document Description
Modified ROI receiving HCS services
Agreement Standard participation agreement that serves as written consent
Authorization
Assessment
HMIS Assessment data entry documenting date of verbal consent and HCS project in
which the consumer is enrolled
Unacceptable Documents
The following items are considered insufficient for documentation of verbal consent for HCS services:
Document Description
HMIS Case
Comments screenshots of case comments.
Basic ROI HCS services.
Using HCS Authorization Assessment
Creating an Assessment
o In consumer’s HMIS HCS program (HD, HN, or TSS), select the Assessments tab.
o Choose the HCS Authorization Assessment
34
o Click on the toggle button for the program the consumer has provided consent for and enter the
date consent was given.
Running HCS Authorization Assessment Report
This report can be used as proof of consent for quarterly audits
o In HMIS, go to the Reports menu
o Select Assessment Based Reports
o Run report GNRL-210 Assessment Details
o Under Assessment Screen select HCS Authorizations with a date range including the consumer’s
enrollment date
o Run report, filter for selected audit consumers and submit with audit package.
35
6. Invoice Template
INSERT ON AGENCY LETTERHEAD
January 1, 2023 - June 30, 2025
PO Number: Invoice Date:
Current
Billing
Month
Prior Billing
Month (previously
unbilled):
Housing Community Support Members
Served Members Served Rate Total
Housing Navigation (HN) $620 $ -
Tenancy Sustaining Services $620 $ -
Housing Deposits (HD)
Pre-Enrollment Outreach* Members
Served Rate
Outreach 8-22 mins $10 $ -
$20 $ -
Outreach over 37 mins $30 $ -
Total $ -
*Limitations of no more than 20 Outreach Encounters in a 90-day period
Payments to Date: $ -
Contract Advance (if applicable):
Advance Recoupment (if applicable):
Total Due: $ - Attachments:
1) Provider Report Encounters Detail tab with first name, last name, date of birth columns
Claims Detail
INSERT Name, Title and Signature of Agency Authorized Staff
36
7. Quarterly Audit Protocol
H&H staff will assess contracted agencies on a quarterly basis to review program compliance. H&H staff
will review records for 5% of consumers who received HN/TSS services and 15% of consumers who
received HD services during the reporting period at each agency. The review process will include:
Category Review Applicable Quarters
Housing Support
Plan (HSP)
•
every HMIS ID sent in audit package, and verify the HSP is
uploaded in HMIS
• Housing Support Plans must be dated within 180 days of
submission and must include required consumer and
agency data as shown on the Housing Support Plan
Template
• Confirmation of percentage of total enrolled consumers
that have an up to date (not older than 180 days) Housing
Support Plan completed.
• Each support plan should show documentation of
consumer housing barriers, identify short- and long-term
goals, and outline HCS services needed to achieve these
goals for each HCS program the consumer has been
Consumer
Consent to
Services
•
consumer selected for review.
• Permitted examples of consent are:
o Participation Agreements
o Modified ROI’s specifically stating consent to
services
o
Housing Deposits
•
Housing Deposit expenses, and expenses do not exceed
$5,000 (or some other amount if consumer has been
nd
Agency Capacity
•
numbers (must include position, title, FTE)
• Auditor will run an enrollment report for each agency on
the last day of the quarter and verify that agency capacity
does not exceed the 25:1 ratio. If agency capacity is below
this ratio, feedback on reaching this goal should be present
ACH Required
Trainings trainings,
37
Scoring Guidelines:
Housing Support
Plan
Meets requirements Housing Support Plans have all required elements completed.
100% of total enrolled consumers have an up to date Housing
Missing Documentation action items
Less than 100% of total enrolled consumers have an up to date
Housing Deposit
Receipts
Meets requirements listed for consumer, and total per consumer expenses do not
exceed $5,000 (or some other amount if approved for 2nd HD
Missing Documentation
documentation does not match HMIS service records or if
documentation is not submitted within 30 days of due date (see
table below), ACH will adjust the following month’s provider
Agency Capacity
Review
Meets requirements Agency is providing services to consumers equaling at least 75%
Approaching standard
Consumer
Consent Missing Documentation Documentation missing
Employee
Training
Meets Requirements Documentation of training submitted
Service
Quarter
Q 1 April
Q 2 July
Q 3 October
Q 4 January
Agency Checklist
Contractors are required to provide the following documentation for each of their selected consumers.
o Housing Support Plan
o Receipts for each service under Housing Deposits for the applicable quarter
o Breakdown of current Direct Service Employees for Housing Navigation and Tenancy Sustaining
services
38
o Documentation of consumer consent to services
o Documentation of completed HCS-required trainings
39
8. Example Housing Support Plan
Note: this section will be updated based on the June 2025 launch of the HMIS assessment-based HSP
Note: An editable version of this form can be found on the HCS website.
1. HMIS ID #
(if applicable)
☐ Housing Transition & Navigation ☐ Tenancy & Sustaining Services ☐ Housing Deposit HSP END DATE _ _/_ _/_ _ _ _
☐ Housing Transition & Navigation ☐ Tenancy & Sustaining Services ☐ Housing Deposit
If changes are after this HSP end date, create a new HSP for authorization.
5. HSP Revision Date _ _/_ _/_ _ includes ☐ Housing Transition & Navigation ☐ Tenancy & Sustaining Services ☐ Housing Deposit
Added Service Activities ________________________________________________________
HSP Revision Date _ _/_ _/_ includes ☐ Housing Transition & Navigation ☐ Tenancy & Sustaining Services ☐ Housing Deposit
Added Service Activities ________________________________________________________
HSP Revision Date _ _/_ _/_ _ includes ☐ Housing Transition & Navigation ☐ Tenancy & Sustaining Services ☐ Housing Deposit
Added Service Activities ________________________________________________________
Developing an individualized HSP must be based upon the housing assessment that addresses identified barriers, includes short- and long-term measurable goals for each issue, establishes the member’s approach to meeting the goal, and identifies when other providers or services, both reimbursed and not reimbursed by Medi-Cal, may be required to meet the goal. An HSP should help the participant and provider identify strengths and attainable housing focused goals. It should be updated at least every 180 days. The HSP should also be revised as a person’s situation changes, and steps are completed, or goals updated. If revised, add the revision date to Box 5.
40
6. Housing Navigation (HN) Service Activities: (Check all that apply and add details to sections 10-14 for each)
☐1. Searching for housing and presenting options
☐ 2. Assisting in completing housing applications
☐ 3. Assisting in obtaining ID and documentation for SSI
☐ 4. Supporting SSI application process
☐ 5. Identifying and securing housing resources to assist with
☐ 6. Identifying and securing resources to cover security deposit,
- time expenses
☐ 7. Assisting with requests for reasonable accommodations
☐ 8. Engaging and educating landlord/property management
☐ 9. Ensuring living environment in prospective unit is safe and
☐ 10. Communicating and advocating on behalf of member to
☐ 11. Assisting in arranging for and supporting details of the move☐ 12. Establishing procedures and contacts to retain housing,
☐ 13. Identifying, coordinating, securing or funding non--
☐
7. Housing Tenancy & Sustaining Service (TSS) Activities: (Check all that apply and add details to sections 10-14 for each) ☐ 1. Providing early identification and intervention for behaviors that may
☐ 2. Education and training on the role, rights, and responsibilities of the ☐ 3. Coaching on developing and maintaining key relationships with ☐ 4. Coordination with the landlord and case management provider to ☐ 5. Assistance in resolving disputes with landlords and/or neighbors to
he unit. ☐ 6. Advocacy and linkage with community resources to prevent eviction ☐ 7. Assisting with benefits advocacy, including assistance with obtaining
☐ 8. Assistance with the annual housing recertification process. ☐ 9. Coordinating with the tenant to review, update and modify their housing
☐ 10. Continuing assistance with lease compliance, including ongoing ☐ 11. Health and safety visits, including unit habitability inspections ☐ 12. Other prevention and early intervention services identified in the crisis
8. Housing Deposit
Is housing deposit assistance authorized for this member? ☐ Yes or ☐ No
Deposit start date _ _ /_ _/_ _ _ _ Deposit End Date _ _/_ _/_ _ _ _
9. Member Strengths identified to assist with goals:
41
10. Activity Number 11. Identified Barriers 12. Goal (short & long term) 13. Action Steps
Responsible
Example: 6.3
(Assisting in
for SSI)
No
transportation
to SSI office; no
phone number
to get in touch
with consumer
Example: 7.10
(Continuing
lease
compliance,
including
st of each month in person to
42
16. My Emergency Contact Person is Name
Phone Number
Agency (if applicable)
Phone Number
Agency (if applicable)
Provider is Phone Number
Agency (if applicable)
19. SIGNATURES
Member Name Member Signature Date
Staff Name Staff Signature Date
Staff Phone Staff E-mail
Supervisor Name Supervisor Signature Date
15. Member’s housing preferences:
HMIS Data Entry: Enter the contact information below within the consumer “contact” fields in HMIS.
43
9. Contractor Dashboard
Quarterly Reporting Period:
☐ FYQ3 / CYQ1 (January 1 – March 30)
☐ FYQ4 / CYQ2 (April 1 – June 30)
☐ FYQ1/ CYQ3 (July 1 – Sept 30)
☐ FYQ2 / CYQ4 (October 1 – December 31)
Date of Report:
Organization: Contact person:
Email:
Number of unduplicated
consumers served (at least one
service encounter) in:
• For current quarter
• Calendar year to date HMIS – Report Library
àHUD Reports à Annual
Performance Report
(APR) à Q4a ‘Total
Active Households’
Note – exclude in count
those without a service
encounter
N/A
Calendar YTD:
Tenancy Sustaining (TSS)
Number of unduplicated
consumers served (at least one
service encounter) in:
• For current quarter
• Calendar year to date
N/A
Calendar YTD:
Housing Deposits (HD)
Number of unduplicated
consumers served (at least one
housing deposit expense) in:
• For current quarter
•
N/A
Calendar YTD:
consumers served (at least one
service encounter) across all
three Housing Community
Supports:
• For current quarter
• Calendar year to date
àHUD Reports à Annual
Performance Report
(APR) Q8a ‘Number
of Households Served’
Note – exclude in count
those without a service
N/A
Calendar YTD:
All HCS projects (agency)
Number and Percent of
consumers who have
maintained or increased their
Analysis à Built In
Reports à Program
Performanceà Income
75% or more
% of consumers served:
44
assessment.
• Contract start to end of
Increased/Maintained
Total Household
☐☐ Does Not Meet Target
HN
Number and Percentage of
consumers enrolled in Housing
Transition Navigation services
permanently housed within 6
months (will report on for the
first time after second quarter)
Analysis à Built In
Reports à Program
Performance à LoT -
Leavers by Destination
Category à Permanent
Housing
Situations/Average
Days in Project (See
detailed guidance
below)
65%
% of consumers served:
☐ Meets or Exceeds Target ☐ Does Not Meet Target
TSS
Number and Percentage of
consumers receiving Tenancy
Sustaining Services who
graduate from services or
maintain housing (ie NOT
exited to the streets,
emergency shelter, unknown,
or other non-permanent
housing destinations)
• Contract start to end of
HMIS – Report Library
àHUD Reports à Annual
Performance Report
(APR)
(See detailed guidance
below)
90%
% of consumers served:
☐ Meets or Exceeds Target ☐ Does Not Meet Target
Reporting Requirement Data Source (Non
HMIS)
Target Metric, If
Applicable
Quarterly Report Results
All HCS projects (agency)
Number and Percentage of
consumers who maintain
health insurance enrollment
• Contract start to end of
quarter
In
development/consultat
ion with ACH DEU team
Number of consumers:
% of consumers served:
☐ Meets or Exceeds Target
☐ Does Not Meet Target
All HCS projects (agency)
Number and Percent of
consumers who have been
enrolled for 15 days with an
individualized housing support
plan
records internally
ACH will audit random
selection of 5% of
consumers for
confirmation
100%
% of consumers served:
☐ Meets or Exceeds Target
☐ Does Not Meet Target
45
Reporting Time Periods
FYQ3 / CYQ1 January 1 – March 30 April 30
FYQ4 / CYQ2 April 1 – June 30 January – June July 30
FYQ1/ CYQ3 July 1 – Sept 30 October 30
FyQ2 / CYQ4 October 1 – December 31 July – December January 30
FY – Fiscal Year
CY – Calendar Year
Additional space for notes or information:
Additional guidance on how to determine Number and Percentage of consumers enrolled in Housing
Transition Navigation services permanently housed within 6 months:
1) In Program Performance (Reports Data Analysis Built In Reports), select reporting date
range and your HCS-HN program from the “Program Name” list and click the “reload” circular
arrow at the top
2) Scroll down to “LoT (Length of Time) – Leavers by Destination Category”:
3) Click the green bar in the “Average Days in Project” column and “Permanent Housing Situations”
row. This will bring up a new window showing all Leavers into permanent housing. Click
“download” at the top and download to excel.
4) In the excel file, sort the “Days in Project” column smallest to largest. Count how many
consumers are at or below 180 days. Tip: click the top (smallest) number and drag down the
column until you’ve reached all values 180 and below. At the bottom of the excel doc will be a
count of the number of selected cells. This is your Number of consumers enrolled in Housing
Transition Navigation services permanently housed within 6 months.
5) To get the percentage, we need to determine the denominator, which in this case is all Leavers
plus Stayers > 6 months.
6) All Leavers can be found at the same “LoT (Length of Time) – Leavers by Destination Category”
section in the “Consumer Count” column and “Totals” row at the bottom:
46
7) Stayers > 6 months can be found in the “LoT in Program” section:
8) Click the bar in the “Average” column and “Stayers” row. This will bring up a new window
showing all Stayers. Click “download” at the top and download to excel.
9) In the excel file, sort the “Project Start Date” column oldest to newest. Count how many
consumers have an enrollment date prior to 6 months before the end of your reporting period.
Example: if the reporting period you are working on is October – December, stayers with an
enrollment date of June 30 or earlier are your stayers >6 months (because consumers enrolled
July-on have not yet reached 6 months of enrollment on December 31st). This number plus “All
Leavers” from (6) is your denominator. Divide your Number of consumers permanently housed
within 6 months from (4) above by the denominator to get Percentage of consumers enrolled in
Housing Transition Navigation services permanently housed within 6 months.
10) Example:
100 consumers permanently housed within 6 months
130 total Leavers
10 Stayers > 6 months
100 / (130 + 10) = 71.4%
Additional guidance on how to determine Number and Percentage of consumers enrolled in Tenancy
Sustaining services who maintain housing:
1) In Annual Performance Report, the number of Stayers (Q5a) plus “Total persons existing to
positive housing destinations” (Q23c) = Number of consumers enrolled in Tenancy Sustaining
services who maintain housing
2) To get the percentage, we need to determine the denominator, which in this case is the number
of stayers from (1) plus the total number of leavers from Q23c minus total persons whose
destinations excluded them from the calculation from Q23c.
Example:
100 stayers (Q5a)
25 exited to positive housing destinations (Q23c)
= 125 consumers enrolled in Tenancy Sustaining services who maintain housing
47
50 total leavers (Q23c)
10 persons whose destinations excluded them from the calculation (Q23c)
125 / (100 + 50 – 10) = 89.3% = Percentage of consumers enrolled in Tenancy Sustaining
services who maintain housing
48
10. Job Aid: HCS Project Entry in HMIS
Enrolling a Consumer in a HCS Project in HMIS
1. Search for the consumer (follow HMIS search protocols)
Only the individual who has been referred should be enrolled into the project, not all household
members.
2. Click on Programs to view the consumer’s Program History and verify the consumer is not actively
enrolled in a HCS program
4. Select the appropriate HCS from the Agency project list and complete enrollment details. Do not
toggle “on” linked household members. Only the individual referred for services should be enrolled.
49
5. HCS Projects & Enrollment Date
• HCS – Housing Navigation (HN): Enrollment Date is when the engagement & coordination with
the individual began
• HCS – Housing Deposits (HD): Enrollment Date is on or before identified move-in date and should
correspond with initial expense date
• HCS – Tenancy Sustaining Services (TSS): Enrollment Date is date of engagement for consumers
in housing, or with an identified upcoming move-in date
6. Complete Current Living Situation Assessment
Complete the Current Living Situation Assessment for each consumer enrolled in an HCS Project. The
assessment needs to be done in the HCS project even if it was done elsewhere in HMIS; however, the
information will be prepopulated (cascade in) if data was previously captured within Coordinated Entry.
50
51
11. Job Aid: Documenting Housing Community Support Services in HMIS
1. Click on PROGRAMS & open the relevant HCS project enrollment
2. Click on Provide Services & select the service
3. Enter (1) Start Date, (2) End Date (same day as start date), and (3) input Service Note summary of
service encounter (NOTE: the service date must fall within the enrollment period)
52
Expense Amount:
• Must be entered within HCS – Housing Deposits Project ONLY
• Enter Expense Amount and Expense Date
• Total service costs cannot exceed $5,000 in total per consumer, per lifetime
4. Click SUBMIT
Documenting Housing Deposits Services in HMIS
1. Go to the HMIS profile of the consumer enrolled in Housing Deposit services with HCS.
2. Under Active Programs section of profile or under the Programs tab open the program
enrollment for HCS Housing Deposits
3. Click the Provide Services tab under the program name
4. Select the service category from the list:
5. Select more detailed service subcategory from the dropdown list
6. Enter Start, End, and actual Expense date, Expense Amount.
7. Funding Source should be listed as HSCA/CalAim
8. Provide a detailed note for what this expense covers
9. Click Submit. Your service will now appear in the History tab within the program.
53
To enter Multiple services of the same type on the same date:
For Security Deposit and Moving Cost Assistance categories you may simply follow the normal service
entry directions.
For all Housing category services (regardless of subcategory) you will see the following error:
Follow these steps to enter multiple Housing services on the same date
1. Create a service following the normal service entry directions, please select the subcategory which
fits the majority of the services you will be entering.
2. Go to the History tab within the Housing Deposit program
3. Select the edit icon next to the housing service
54
4. In the Expenses section of the service select Add Expense
5. Fill in the amount, funding source, dates, and detailed explanation of this additional Housing
expense and submit.
Your new expense will now appear in the Expense section of the service.
55
12. Job Aid: HCS Dual Enrollment Report
Report Purpose: This report can be run as part of agencies’ routine Quality Assurance checks to
ensure that consumers enrolled in their HN/TSS projects are not also dual-
enrolled in either their own or another agency’s HN/TSS projects, with the caveat
that there is an allowable 30-day overlap period.
Report Access: HMIS users with Looker/Data Analysis licenses may view this dashboard and run
this report.
1. From the home screen in HMIS, select the icon at the top of the screen with the nine squares, and
then “Reports” “Data Analysis” “Alameda Clarity System Reports” “HCS Dual Enrollment
Dashboard – HCS-HN & HCS-TSS”, and click “run”
11. On the following screen, the Dual-enrollment dashboard displaying HCS consumers currently
dual-enrolled will be displayed, like this:
56
This dashboard can be used to quickly get a snapshot of HCS TSS/HN dual-enrollments. If providers
notice a consumer of theirs listed that does not have a plan for disenrollment by either their agency
or the agency with which the consumer is dual-enrolled, providers can alert the H&H HCS team at
calaim@acgov.org to discuss. Keep in mind that the second to last column on the right lists “days
since project start.” Enrollments less than 30 days old are within the allowable overlap period.
12. For downloading the full data set to excel to allow for tracking and managing the dual-enrollment
data, hover your cursor to the right of “HCS Dual Enrollment HCS-HN…Dual Enrollments Only
View”, where three dots will appear (highlighted below).
13. Click the three dots and select “Download data”, then select excel spreadsheet from the format
drop-down menu. Click the arrow next to “advanced data options” if you’d like to change the
report output format (optional), otherwise select “Download”.
14. Once the file is downloaded and opened, you can filter for consumers enrolled with your agency
using the filter function.
57
13. Job Aid: Uploading Housing Support Plans to HMIS
Note: this section will be updated based on the June 2025 launch of the HMIS assessment-based HSP
1. Pull up the consumer’s profile and go to the “files” tab at the top
2. Select “ADD FILE” at the top right, which will lead to this page:
3. Leaving the “Category” as “1. Core Housing and Eligibility”, select “Housing Plan” the Predefined
Name dropdown list
4. Click “Select File” and find the Housing Support Plan you’d like to upload, then click “open”
5. Do NOT turn on the “private” toggle
6. Click “Add Record”. Your document will now be listed in the consumer’s files tab
7. If this doesn’t work, click the “Basic Uploader” option and follow steps 3-6
58
14. TSS Evaluation How-To
Note: this section will be updated based on the June 2025 launch of the HMIS assessment-based HSP
Key Points
• Consumers are eligible for Tenancy Sustaining Services as long as necessary
• This assessment is a tool to help demonstrate whether on-going services are needed or
whether a consumer is ready to end services
• The assessment should be completed every 180 days after the first year of service
• You may complete this assessment with the consumer present if helpful, but this is not
required; it was designed to be able to be completed without the consumer present.
1. Navigate to the Assessments tab within the consumer’s TSS project, find the Housing Community
Supports TSS Evaluation and click “start”
Figure 1: Screenshot of Assessments tab
2. Complete the fields at the top of the assessment
1. Assessment Date (this is the date the evaluation is completed)
2. Agency Contact/Case Manager (this should be the person who is completing the assessment)
3. Service provider organization name from the dropdown list
59
Figure 2: Screenshot of start of assessment
3. Complete Evaluation Criteria, Goals and Action Steps: 20 True/False Questions
2. Moving on to the criteria section, read each carefully and select “true” or “false” from
the dropdown list, answering to the best of your knowledge. It may be helpful to consult
external sources of information, such as the Community Health Record, to help in your
responses, but this is not required.
3. Under each criteria marked “false”, a text box and a dropdown question about
timeframe for completion will pop open. For a minimum of three criteria marked “false”,
provide a measurable (SMART) goal, needed action steps, person responsible, and the
estimated timeframe for completion of that goal. If consumers are assessed as having
fewer than 3 false criteria but you are requesting continued services, you must submit a
time-limited measurable goal for each false answer. The timeframe can be up to 6
months since the evaluation is to be completed every 180 days. Note: minimum of 3
goals are only required in cases where continued services are recommended (see step 4
below). If it is determined that services are no longer needed (ie consumer is
graduating), goals are not required.
Figure 3: Screenshot of criteria 1-2 and popups when “false” is selected
15. Complete Case Manager Recommendation to Continue or Discontinue Services
a. After completing criteria #20, note the number of criteria marked “true” either by manually
counting the “trues” or by saving and exiting the assessment and noting the score in the
“details” column under Assessment History (then re-open the assessment using the pencil
icon).
b. Next to “Case Manager Assessment: Consumer Needs Continued Services”, select “Yes” or
“No”. Your recommendation to continue services or not is an important component of this
evaluation, as you know the consumer’s needs and goals best.
i. It is recommended that graduation from services be considered for those that
score 16 or above, however you may recommend continued services even when
this is the case, if ongoing services are necessary, in your opinion, for the
consumer to stay successfully housed.
c. If “Yes” is selected: this means you are advocating that continued services are needed. You
should provide a rationale for the need of continued services in the text box that pops up
(and ensure that a minimum of 3 goals are completed- see step 3 above). This rationale is
60
required in cases where the score is 16 or higher. In cases where the score is 15 or lower, you
can leave this blank or simply write “does not meet threshold score”.
d. If “No” is selected: you are advocating that the consumer is stable enough such that they no
longer require TSS, discuss with your supervisor the needed next steps to move towards
program exit.
Figure 4: “Case Manager Assessment: Consumer Needs Continued Services” and rationale text box.
16. Do NOT turn on the “private” toggle, and click “SAVE”
17. Editing a Completed Assessment
If you need to edit or make corrections to a completed assessment, you may select the pencil icon
next to the existing assessment under “assessment history”. It is very important when making
corrections/edits to a previously completed assessment to update the “Assessment Date” at the top
to reflect the date that changes were made. For example if the assessment was originally completed
on June 30, 2023, this will be prepopulated when you re-enter the assessment at a later date. If
edits are made to the assessment, you must change 6/30/23 to the date you are making the edits.
61
15. Outreach Policy: Pre-Enrollment
This policy is designed to clarify and add specific guidelines to the expectations around pre-enrollment
outreach. If at any point in this process a consumer is located and either accepts or declines services,
then there is no need to continue with the outreach efforts.
For tracking, Quality Assurance, and verification purposes, all outreach attempts need to be
documented in the HMIS Notes section. If outreach is not documented in HMIS, ACH staff may ask for
continued outreach beyond the parameters listed below. If at any point ACH staff believe that outreach
has not been sufficient, they may request additional time and methods to locate and serve a consumer.
A core part of outreach is to attend the Regional Housing Coordination and/or TAY Huddle meetings,
where providers can bring up hard-to-find consumers and collaborate with other service providers who
might have helpful information. Housing Coordination meetings are broken down by region:
o North County: Berkeley, Albany, Emeryville (Andrea Zeppa: Andrea.Zeppa@acgov.org)
o Oakland (Lynette Ward: Lynette.Ward@acgov.org)
o Mid County (Phil Clark: Phil.Clark@acgov.org)
o East: Dublin, Pleasanton, Livermore (Hanna Toda: Hanna.Toda@acgov.org)
o South: Fremont, Union City, Newark (Hanna Toda: Hanna.Toda@acgov.org)
o TAY (Youth) (Amanda McKinney: Amanda.McKinney@acgov.org)
If you are not already attending these meetings, please email the regional coordinator listed above for
the regional meeting(s) you would like an invitation for, depending on where you believe the consumer
is currently staying. It may make sense for one person to attend for the HCS team. Requestor will be
added to the recurring invite and can attend when needed.
Pre-enrollment outreach expectations (first 60 days):
Add a Public Alert in HMIS to contact HN if contact is made/whereabouts are known
AND
Attend and present the consumer at the relevant Regional Housing Coordination Meeting at least once
AND
Have at least six documented (see “HMIS Data Guidance” below) attempts of any combination of the
following strategies, with at least one being in-person
1. Phone calls/voicemails to consumer
2. Outreaching to any contacts in HMIS and the CHR
3. Contacting the person who completed or recently updated the Coordinated Entry
Assessment
4. Visiting consumer’s last known address/recent locations
5. Mailing a letter to consumer’s last known address
Notes on contact attempts should be brief but paint a clear picture of what kind of outreach was
attempted. Contractors are encouraged to attempt more than the minimum six attempts. There should
be at least one outreach attempt every 10 days, and contractors should make reasonable attempts to
conduct initial outreach within 24 hours of referral receipt.
HMIS Data Guidance: Pre-HCS enrollment
62
Until a referred person has been contacted, consented for services, and enrolled into the appropriate
HMIS HCS project, outreach notes must be captured within the global notes section of the individual’s
HMIS profile:
There are eight HCS-specific dropdown options in the “Category” field, which have both a method (in-
person or telephonic) and length of time listed:
When logging pre-enrollment outreach attempts for HCS referrals, selecting the appropriate “HCS”
dropdown option is required. Example: a pre-enrollment outreach attempt involved a phone call that
lasted 10 minutes with the prospective consumer. This should be logged as “outreach attempt- HCS-
telephonic- 8 min- 22 min”. Important: Pre-enrollment outreach attempts that are successful and lead
to HCS enrollment ALSO must be logged in the same manner as described above.
If you are unable to attempt or exhaust all of these strategies prior to the 60 days, please email
CalAIM@acgov.org for guidance on next steps.
AFTER 60 Days:
If you have met the standards outlined above for days 1-60:
You are encouraged to request a new referral
And
Attempt to contact one more time
And
Continue to present the consumer in the relevant Regional Housing Coordination Meeting
At 90 Days:
You may request to return the referral to H&H by e-mailing CalAIM@acgov.org
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If ACH approves the return of the referral, ACH will also confirm if Housing or HCS organization should
work with the Housing Resource Center (HRC) for the referred person to be exited from Coordinated
Entry.
Unable to Complete:
Contractors that are not able to complete the minimum 6 documented attempts during the first 60 days
of outreach may be asked to retain the referral until the minimum requirements have been completed
and entered in HMIS, beyond the 90 days outlined in the policy.
If a contractor has more than 40 referrals in the pre-enrollment outreach phase, ACH may pause
referring new Housing Navigation consumers until the outstanding referrals have been resolved.
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16. Grievance Policy
Housing and Homelessness Services (H&H)
Housing Community Supports (HCS) Grievance Policy
1. Introduction
This document provides policies and procedures for Alameda County’s H&H Housing Services Office and
Housing Community Supports (HCS) providers to ensure that any consumer may submit a grievance,
receive a response, and, if necessary, appeal the response related to the provision of HCS services in a
consistent, fair, and standard manner. This policy also covers requirements for tracking and reporting on
grievances and appeals.
2. Definitions
• Appeal – an appeal is the elevation of a grievance to H&H for review by a consumer who is
dissatisfied with their HCS-contracted provider’s response to their initial grievance.
• Consumer – a person who receives Housing Community Supports services from a ACH-
contracted HCS provider.
• DHCS – California Department of Health Care Services entity tasked with developing initiative to
reform the Medi-Cal program and, in turn, improve the quality of life and health outcomes of
Medi-Cal members.
• Grievance – an expression of dissatisfaction with any aspect of Housing Community Supports
services provided. A grievance may or may not allege a failure to follow the prescribed policies,
procedures, and practices of Housing Community Supports in a consistent and non-
discriminatory manner resulting in a negative impact on a consumer.
• ACH – Alameda County’s Health Care Services Agency, serving as the intermediary between
Managed Care Plans and HCS providers in administering the HCS program.
• Hearing – a meeting during which an HCS-served consumer and HCS provider may provide
evidence in support of their positions related to a grievance. This evidence is then used to make
a determination. Consumers may be accompanied by and receive assistance/guidance from an
advocate (a consumer-designated representative, i.e., a family member, friend, service provider,
or trained advocate) during a hearing.
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• Housing Community Supports – medically appropriate, cost-effective services that are covered
under the California Medicaid State. Community support services include Housing Transition
Navigation Services; Housing Deposits; and Housing Tenancy and Sustaining Services.
• Investigation – a process which may be undertaken by H&H to review a grievance, and, in the
event that a consumer has brought an appeal to H&H, the result or resolution by an HCS
provider. The investigation may cover both how the grievance was handled and the resolution.
• Managed Care Plan – entity licensed by DHCS to provide health care to Medi-Cal enrollees.
Alameda Alliance for Health is the Managed Care Plan in Alameda County.
• Non-discrimination – the requirement to ensure that HCS services are available to all eligible
persons and administered without discrimination based on race, ethnicity, preferred language,,
religion, national origin, sex, age, familial status, disability, sexual orientation or marital status.
This includes requirements to comply all applicable civil rights and fair housing laws and
requirements.
• H&H - – ACH’s Housing and Homelessness Services serves to implement expanded services and
supports and lead the development of a strategic framework to address homelessness within
Alameda County.
3. Policy Scope
This Policy applies to all Housing Community Supports providers contracted by H&H to provide Housing
Transition and Navigation, Tenancy Sustaining, and Housing Deposit services.
4. Policy Description
4.1 Purpose
This policy is intended to ensure that consumers in HCS services, including Housing Transition
and Navigation, Tenancy Sustaining, and Housing Deposit services, have a consistent and clear
ability to file a grievance, receive a response, and, if necessary, appeal any aspect of their
experience or treatment in a similar manner and timeframe, regardless of from what HCS
provider they receive services.
4.2 Policy
HCS providers shall follow their own agency or program procedures for receiving and
responding to grievances related to the delivery of HCS services, provided that the applicable
procedures:
• are clearly stated and made available to all consumers;
• allow the consumer to file their grievance and have it reviewed or heard by someone who is
not involved in the grievance; the person reviewing the grievance and making the
determination must be at a higher level within the organization;
• allows consumers to receive assistance in making their grievance known including
reasonable accommodation(s);
• include the ability to have an advocate at any meeting or hearing;
• provide for a written response with a determination about the actions alleged and a
proposed resolution if warranted, within a set and reasonable period of time, not later than
14 days from receipt of the grievance.
Any consumer grievance not resolved by the HCS provider must be submitted to H&H, serving as
oversight for Housing Community Supports providers and intermediary with Managed Care Plans.
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HCS providers and H&H shall keep a log of all grievances received, according to the procedures set out
below. Provider grievance logs must be made available for review upon request by H&H, which will use
the information to recommend refinements and improvements in the process and delivery of services.
5. Procedure
5.1 All HCS providers will provide consumers with information about how they may file a grievance.
This information should be made available at time of enrollment in HCS services and upon
request during service duration period.
5.2 HCS providers will follow their procedures and document the results of any grievances received
and actions taken in accordance with their internal procedures and supervision, provided these
reflect the above required elements in 4.2.
5.3 HCS providers and H&H will maintain a log of all grievances received regarding any aspect of
HCS services. This log must at minimum record:
a. when the grievance was first received;
b. the primary concern or topic raised in the grievance and which aspect of
HCS services (HD, HN, or TSS) the consumer was concerned with;
c. whether the grievance included a concern regarding discrimination, and what
type of discrimination was cited.
d. when a response was submitted;
e. what finding was made and what action was taken;
f. whether the finding was appealed, and the outcome
5.4 The HCS provider’s log should be kept updated, with each step recorded within 48 hours of its
conclusion. H&H may request to review the log at any time.
5.5 HCS providers will notify consumers at the time of their final response that if they are
dissatisfied with the result, they may notify the HCS provider as such. The HCS provider will
submit the grievance appeal to H&H at calaim@acgov.org within 24 hours or the next business
day. HCS providers must also inform consumers that they may file a discrimination complaint
directly with DHCS.
At this point, the procedures followed are dependent upon whether the consumer is enrolled in
Managed Care or not. If they are enrolled in Managed Care:
5.6a All grievances from a consumer enrolled with a Managed Care Plan (Alameda Alliance for
Health) that are sent to H&H will be submitted to the appropriate MCP per DCHS grievance
regulations.
5.7a The HCS provider agrees to cooperate with and participate in both County and Managed Care
Plan grievance procedures including responsiveness within required time limits by the
Managed Care Plans and State and/or Federal law. The HCS providers shall comply with both
County and Managed Care Plan’s resolution of any such complaints or grievances including
specific findings, conclusions, and orders of California Department of Managed Health Care
(DMHC) or DHCS and shall adhere to these procedures for the prompt receipt, processing, and
resolution of such matters.
If the consumer is not enrolled in Managed Care:
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5.6b H&H will respond to all appeals within 10 business days and will provide consumers with a
written determination of whether the grievance was appropriately handled and will either
uphold the HCS providers’ determination or initiate an investigation, which may result in
upholding the determination. Alternatively, H&H may issue a different decision and proposed
resolution. H&H’s determination is final and does not allow for an appeals process.
5.7b If H&H opens an investigation, they may consult with HCS providers as they investigate. HCS
providers must share with H&H any information they have collected regarding the grievance
and participate in any hearings or meetings called to review the result.
6. Policy Location
This Policy will be held in within the HCS Provider Manual and on the HCS website.
7. References, Related Resources, or Appendices
The HUD office of Fair Housing and Equal Opportunity online complaint portal
https://www.hud.gov/program_offices/fair_housing_equal_opp/online-complaint
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17. HCS Policy: PMPM Reimbursement for Consumers Without a Documented TSS
Evaluation
This document serves to (a) reiterate requirements that HCS Contractors complete and submit (via
HMIS) to ACH a “TSS Evaluation” for each consumer enrolled in TSS after 1 year of enrollment, and every
180 days thereafter; and (b) outline ACH’s policy regarding PMPM reimbursement to Contractors for
consumers who do not have a submitted TSS Evaluation.
As stated in the 2024 HCS-SAN contracts4,5 and the HCS Provider Manual6, completed TSS Evaluations
are required for each TSS consumer after one year of services, and every 180 days thereafter. These
evaluations serve to assess, document, and justify the ongoing need for HCS-TSS services.
Effective October 1, 2023, Contractors will not receive PMPM reimbursement for services to TSS
consumers who do not have a completed TSS Evaluation that documents the needs for continuing
services on file by the 15th of the month that the TSS Evaluation was originally due. The table below
illustrates this timeline:
1 This is the last date for which PMPM reimbursement will be approved if TSS Evaluation is not completed
2 If TSS Evaluation not completed by this day, services in the post-authorization period will not be reimbursed
As an example, say a consumer’s service authorization period ends June 30th, and the original TSS
Evaluation due date is June 1st. If the TSS evaluation is not completed by June 15th, then ACH will not
reimburse for services after July 1.
Transition Planning
If and when services are discontinued for any reason, contractors are responsible for supporting
consumers with transition planning into other programs and services that meet their needs. This may
involve coordination with other entities to ensure the individual has access to supports needed to
maintain successful tenancy7,8.
4 Exhibit A, Terms of Service #10, “Contractor shall provide the documentation required for the County to submit claims…”
5 Exhibit A, Additional Requirements: “For TSS clients (that need to continue services for more than 12 months), Contractor shall attach a
completed “TSS Needs Evaluation” to their HSP at each update.”
6 “Contractors are required to complete and upload to HMIS a “TSS Evaluation Checklist” for each consumer after one year of services, and
every 180 days, thereafter. TSS Evaluation Checklists serve to assess whether services are still necessary and provide a mechanism for
contractors to justify that need”. 7 Exhibit A, Referral, Enrollment, and Disenrollment
8 Exhibit A, Housing Tenancy and Sustaining Services
Authorization
End Date1 Contractor that TSS
October 31 January 1 January 15
November 30 February 1 February 15
December 31 March 1 March 15
January 31 April 1 April 15
February 28 May 1 May 15
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If inability to contact or locate the consumer is causing significant delays in completing the TSS
Evaluation or other required documents, contractors shall email calaim@acgov.org to ask for guidance
on next steps.
ADDEMDUM: Housing Community Supports Policy:
Contractor PMPM Reimbursement for Consumers Without a Documented Housing Support Plan
This document serves to (a) reiterate requirements that HCS Contractors complete a Housing Support
Plan (HSP) for every enrolled consumer; and (b) outline ACH’s policy regarding PMPM reimbursement to
Contractors for consumers who do not have a submitted Housing Support Plan.
As stated in the 2024-2025 HCS-SAN contracts9 and the HCS Provider Manual10, HCS Contractors are
required to complete a Housing Support Plan (HSP) for each enrolled consumer within 15 days of
enrollment, submit (via HMIS) to ACH the HSP within 30 days of enrollment, and review and revise the
HSP every 180 days thereafter and as needed in between.
Housing Support Plans serve to:
• document the consumer’s need for services,
• outline the housing goals the consumer has (SMART goals), and
• describe the service and action plan in place to help the consumer work towards and reach
those goals
In addition, up-to-date HSPs serve as the documentation used to justify an extension for Housing
Navigation and Tenancy Sustaining services authorized by the Managed Care Plan.
Beginning January 1, 2025, ACH staff will send Contractors a monthly list of consumers whose HSPs are
missing, out of date, or will soon be expiring. There will be a due date included in the list that will
depend on the date of the most recent HSP. If the Contractor does not upload (as “Housing Plan” from
predefined list) to HMIS an HSP by the specified due date, that consumer will not be eligible for PMPM
reimbursement effective the 1st of the month following the due date specified. Only consumers that
have been enrolled for 3 months or longer will be subject this policy, and ACH reserves the right to
adjust this timeline.
Additionally, HSPs found during audit reviews to not meet quality standards will not be eligible for
PMPM reimbursement if an updated and standard-meeting HSP is not submitted within 30 days of
receiving feedback from ACH staff.
If an HSP is submitted after the due date, that consumer may have their PMPM reimbursement
eligibility reinstated effective the 1st of the month of the month the HSP is completed and uploaded.
9 Exhibit A, Housing Support Plan
10 “All consumers must have an individual Housing Support Plan identifying the need for the Housing Community Support services (completed
within 15 days of HCS enrollment and uploaded to HMIS within 30 days of enrollment)”
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18. HMIS Guidance and Payment Summary
Pre-Enrollment Outreach
ONLY for those referred
for HCS services. Pre-enrollment
outreach includes both in-person
attempts in the community, and
attempts that are virtual
(phone/video/emails), community
searches, and general
tracking/locating activities such as
in-custody searches, reaching out
to collateral contacts, etc.
Successful outreach that results in
engagement, consent for services,
and enrollment should also be
logged as pre-enrollment
outreach.
‘category’ data field, selecting the appropriate length of time spent on
attempt:
- 23 min-37min: $20 per encounter
- Over 37 min: $30 per encounter
Pre-enrollment outreach attempts less
than a duration of 7 minutes should also
be entered into HMIS.
Restrictions: Up to 20 pre-enrollment
outreach attempts may be reimbursed
per consumer, over a 90-day period.
The final day for which a pre-enrollment
outreach attempt is eligible for
reimbursement is the date of HCS project
enrollment, or 90 days after ACH referral
to contractor for HCS services (whichever
Enrolled in Housing Navigation (HN) or Tenancy Sustaining Services (TSS)
Service Type Demonstrating how/where to log in HMIS Payment
Direct Contact: An instance of
direct Provider-to-Consumer
Interaction (either in-person or via
phone/other technology) during
which HN/TSS services occurred
Guidance:
HMIS Service Category: Case Management
HMIS Type of Service: Individual Meeting
$620 per consumer per month with:
1) at least one Direct Contact during the month
AND
2) Uploaded HSP w/in 30 days of enrollment. HSP
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Indirect Contact: Linkages/further
support: (examples)
- Case manager follows up
with medical/psychiatric
clinic on a referral for
services
- Case manager discusses
and schedules a housing
interview with a property
manager
- Case manager has a
meeting with the
consumer’s landlord (w/o
the consumer present) to
discuss a pending unit
repair that has been
HMIS Service Category: Choose most appropriate depending
on nature of service (Health Care, Housing, Legal, Mental
Health, etc.)
HMIS Type of Service: Referral
Not billable as a standalone activity.
NOTE: $620 per consumer per month rate with at least
one direct contact considers BOTH direct care AND
other time spent supporting the consumer, including
but not limited to:
• Direct contact encounters
• Linkages and follow up support
• No-shows (and follow-up with consumers who
are lost to service)
• Documentation time
• Flexible funding for consumer needs
• Supplies
• Administration
Post enrollment outreach
the effort does not result in a direct
contact)
• In-person/Telephonic
• Community outreach
• Tracking locating activities; in-
custody searches, reaching out
HMIS Service Category:
HMIS Type of Service: Assessment/Service Plan
NOTE: do not enter into notes as HCS Outreach as stated
above; which is for Pre-Enrollment activities only.
Required Documentation
Document Demonstrating how/where to log in HMIS Payment
HN and TSS: Housing Support Plan
(HSP):
A Housing Support Plan (HSP) must be
completed and uploaded in HMIS:
1) within 30 days of enrollment,
File Category: Core Housing and Eligibility
Predefined Name: “Housing Plan”
Member Per Month (PMPM) payment, with 30-day
grace period after enrollment (see above).
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TSS only: Tenant Sustaining Service
Evaluation
- Required after 12 months of
enrollment, and every 6
months thereafter. The TSS
evaluation must be completed
within 30 days of notification
from ACH
- Note: TSS evaluation will be
combined with HSP in HMIS
with the goal to launch in
Spring 2025. Additional
Guidance forthcoming
TSS project:
Once finalized, the combined HSP/assessment will be an
assessment within the HN/TSS project
completed within the past 180 days (and HSP
uploaded within past 180 days) is required for Per
Member Per Month (PMPM) payment
Notes:
- Service providers are expected to maintain frequent contact (generally once per month but more frequent depending on treatment
goals) with consumers including home visits, phone calls, and face to face visits in the community. Regular contact with consumers is
important to maintain active and positive relations; and
o Ensure all housing documentation is completed and updated as needed.
o Ensure that there are connections to (new and maintained) services that support housing stability such as income
(SSI/GA/employment), health coverage and care, and any other community supports that further the self-sufficiency and healthy
inter-dependence.
o Engage in an active housing search that does not solely rely on the CE match system.
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This includes but is not limited to connections to family, seeking shared living opportunities, applying for affordable
housing and Public Housing Authority resources, and following up with housing matches as available (Housing
Navigation).