Community Transition Waiver

CalAIM Community Transition Services / Nursing Facility Transition to a Home — Complete Program Description

What Is This Program?

Community Transition Services (also called "Community or Home Transition Services" or "Nursing Facility Transition to a Home") is one of 14 Community Supports available under CalAIM. It is specifically designed to help Medi-Cal members leave nursing facilities and return to living in their own home or a private residential setting in the community.

Members transitioning from a nursing facility to a private residence where they will be responsible for their own expenses receive funding for set-up services such as security deposits, set-up fees for utilities, and health-related appliances such as air conditioners, heaters, or hospital beds. Community Health Group

The program's core purpose is simple but life-changing: many people living in nursing facilities want to return home but cannot afford the one-time costs of setting up a household after a long institutional stay. Community Transition Services removes those financial barriers and ensures the home is ready to support the member's health and safety before they leave the facility.

🏠 What the Program Covers

Community Transition Services covers the one-time, non-recurring expenses necessary to set up a safe, functional household for a member returning from a nursing facility. All services and goods must be medically necessary and based on the member's individual needs.

1. Housing Setup and Move-In Costs

Security deposits required to obtain a lease on a private residence or public subsidized housing unit

Application fees for housing units (where applicable)

Moving costs to transport the member and any essential belongings from the nursing facility to their new home

First month's utility deposits and setup fees for gas, electricity, water, telephone, and heating services to ensure the home is functional from day one

2. Health-Related Appliances and Medical Goods

Funding is available for health-related appliances such as air conditioners, heaters, or hospital beds. This reflects the medically-focused nature of the program — appliances are covered specifically because they are necessary for the member's health and safety, not simply for comfort. Examples include: Community Health Group

Air conditioners — for members with respiratory conditions, cardiac conditions, or those on medications that impair heat tolerance

Heaters and space heaters — for members with conditions aggravated by cold temperatures

Hospital beds — for members who require an adjustable bed for medical reasons, wound care, or post-surgical recovery

Shower chairs and bathing equipment — medically necessary adaptive equipment to enable safe bathing

Bed rails and positioning aids — to prevent falls and support safe transfers

Other health-specific equipment not otherwise covered through standard Medi-Cal Durable Medical Equipment (DME) benefits

3. Essential Household Furnishings and Goods

For members returning from long nursing facility stays who have no household belongings, basic essential items can be covered, including:

Bedding — mattresses, pillows, sheets, and blankets

Basic furniture — bed frame, table, chairs, and basic seating

Kitchen essentials — dishes, pots, pans, utensils, and cups necessary for meal preparation

Bathroom necessities — towels, shower curtain, and bath mat

Cleaning supplies — basic household cleaning products and equipment

4. Home Preparation Services

One-time cleaning of the unit prior to the member moving in, where necessary for health and safety

Minor repairs needed to make the home habitable and safe before the member's return

Pest eradication when required for health or safety

5. Care Coordination and Transition Planning

Beyond physical goods and financial assistance, the program includes transitional care coordination to ensure the move from the nursing facility to home is safe and clinically supported:

Discharge planning coordination between the nursing facility, the member's managed care plan, and community providers

Connection to home and community-based services (HCBS) including In-Home Supportive Services (IHSS), which can continue after the transition

Referrals to ongoing community supports such as Personal Care and Homemaker Services and Home Modifications

Benefits enrollment assistance for SSI/SSP, CalFresh, and other income and support programs the member will need to maintain housing independently

Connection to Enhanced Care Management (ECM) for members with complex ongoing care needs

✅ Who Is Eligible

Members are eligible for Community or Home Transition Services when they are currently receiving medically necessary nursing facility Level of Care services and in lieu of remaining in the nursing facility or a recuperative care setting are choosing to transition home and continue to receive medically necessary nursing facility LOC services; have lived 60 or more days in a nursing home and/or recuperative care setting; are interested in moving back to the community; and are able to reside safely in the community with appropriate and cost-effective supports and services. Santa Clara Family Health Plan

In summary, a member must:

Be currently residing in a nursing facility (or recuperative care setting)

Have lived in the facility for 60 or more days (note: Medicare-paid short-term rehab stays do not count toward this 60-day requirement)

Be clinically stable enough to live safely in the community with appropriate supports

Be willing and interested in returning to the community — participation is entirely voluntary

Be enrolled in a Medi-Cal Managed Care Plan that has elected to offer this Community Support in their county

🏡 Where Members Can Transition To

This program supports transitions specifically to private residences — settings where the member is responsible for their own living expenses. Eligible settings include:

Private homes or apartments the member owns or rents

Public subsidized housing (Section 8, public housing authority units)

Shared living arrangements where the member maintains their own room/unit

Note: This service is distinct from the Nursing Facility Transition/Diversion to Assisted Living Facilities (ALF) Community Support. If a member is transitioning to an assisted living facility, adult residential facility, or residential care facility for the elderly rather than a private home, they would access the ALF Transitions benefit instead.

💰 Program Limits and Parameters

ParameterDetailCost to member$0 — fully covered through Medi-CalMaximum dollar capUp to $7,500 per member for non-recurring set-up expensesMinimum facility stay required60 days in nursing facility or recuperative care (Medicare-paid rehab stays excluded)FrequencyOnce per lifetime (with limited exceptions if circumstances change significantly)Authorization timingServices should be initiated while still in the facility and can begin prior to dischargeAvailable statewideYes — offered in counties where MCPs have elected this Community SupportParticipationFully voluntary — members may decline without losing other Medi-Cal benefits

If a member reaches their lifetime maximum of the Environmental Accessibility Adaptations Community Support, funds for non-recurring set-up expenses may be used through Community Transition Services for related needs. CA

❌ What Is NOT Covered

Room and board — ongoing rent and food costs are the member's responsibility (though Transitional Rent may assist with up to six months of rent for eligible members)

Ongoing utility bills — only initial setup fees and first-month coverage; ongoing monthly costs are the member's responsibility

Duplicate services — cannot cover items already covered by other state, local, or federal programs

Aesthetic or non-medical improvements — items must serve a direct health or functional purpose

Assisted living or board and care facilities — those transitions are covered under a separate benefit (ALF Transitions)

🔗 How Community Transition Services Connects to Other CalAIM Programs

This program works best as part of a coordinated package of supports. Members transitioning from a nursing facility can simultaneously access several other CalAIM services:

Members may receive Housing Transition Navigation Services, Housing Deposits, and/or Environmental Accessibility Adaptations at the same time as Community Transition Services as long as the services provided are nonduplicative, distinct, and necessary. CA

The full transition support package can include:

STEP 1 — Community Transition Services → One-time setup costs: security deposit, appliances, household goods, cleaning, moving expenses STEP 2 — Home Modifications (Environmental Accessibility Adaptations) → Physical modifications to make the home safe: grab bars, ramps, stair lifts, PERS device (up to $7,500) STEP 3 — Transitional Rent (effective Jan 2026 for eligible members) → Up to 6 months of rental assistance to stabilize housing after leaving the nursing facility STEP 4 — Personal Care & Homemaker Services → In-home assistance with daily living activities to support continued independence STEP 5 — Enhanced Care Management (ECM) → Ongoing care coordination across all health and social service systems STEP 6 — In-Home Supportive Services (IHSS) → State program providing ongoing personal care services that can continue indefinitely

👥 Difference Between Community Transition Services and California Community Transitions (CCT)

It is important to note that there are two separate but overlapping programs for nursing facility transitions in California:

CalAIM Community Transition Services (CTS) — covered in this document — is a Medi-Cal Managed Care Community Support administered by each member's Managed Care Plan. It covers one-time move-in costs up to $7,500.

California Community Transitions (CCT) is a separate federal Money Follows the Person demonstration program administered by DHCS directly. It provides transition coordination services through a lead organization and can serve members for a longer period. CCT transition services are currently available through 2027. Members may be eligible for both programs, but cannot receive duplicative services from both at the same time. California Health Care Foundation

📈 Why This Program Matters

The cost of nursing facility care in California averages over $9,000 per month. By helping members transition safely to the community, this program delivers profound benefits:

For members: Restores independence, dignity, and the ability to live in a setting of their own choosing rather than an institution

For families: Reconnects members with family and community life

For the health system: Community living is dramatically less expensive than ongoing nursing facility placement, making this one of the highest-value investments Medi-Cal can make

For communities: Keeps older adults and people with disabilities living as integrated community members

How to Access This Program

Referrals can be initiated by:

The member or their family by contacting their Medi-Cal Managed Care Plan directly

A nursing facility social worker or discharge planner identifying members who wish to return home

An ECM Lead Care Manager working with the member during their facility stay

A primary care physician or other health professional

IHSS county staff working with the member on long-term care planning