Short Term Post Hospitalization (STPHH)

CalAIM Short-Term Post-Hospitalization Housing (STPHH) — Complete Program Description

What Is STPHH?

Short-Term Post-Hospitalization Housing (STPHH) provides members who are experiencing or at risk of homelessness and who have high medical or behavioral health needs with the opportunity to continue their medical, psychiatric, or substance use disorder recovery immediately after exiting an institution. STPHH provides individuals with ongoing supports necessary for recuperation and recovery such as gaining or regaining the ability to perform Activities of Daily Living, receiving necessary medical and psychiatric or substance use disorder care, case management, and beginning to access other housing supports such as Housing Transition Navigation services. L.A. Care Health Plan

This is one of the most critical and targeted Community Supports in the CalAIM initiative, addressing a gap that causes enormous human suffering and healthcare system costs: people are discharged from hospitals and institutions with nowhere safe to go. Without stable housing, they cannot rest, take medications, follow care instructions, or avoid the conditions that sent them to the hospital in the first place — leading to rapid readmission and a dangerous cycle of institutionalization. STPHH breaks that cycle by providing a safe, supportive place to land.

STPHH is provided through California's 1115 waiver, which gives it a distinct federal authorization from most other Community Supports and underscores DHCS's recognition of its critical role in the care continuum. NASHP

🏠 What Is Included — Core Benefits

1. Safe, Stable Interim Housing

The foundation of the program is a safe place to stay. At a minimum, the service includes interim housing with a bed and meals, and ongoing monitoring of the individual's ongoing medical or behavioral health condition, such as monitoring of vital signs, assessments, wound care, and medication monitoring. Partnershiphp

Depending on the facility and the member's individual needs, the housing setting typically includes:

A private or semi-private furnished room in a safe, stable residential facility

Access to bathrooms and shared common areas

A home-like, non-institutional environment

Security and safety measures to protect residents

Staff available during facility hours for support and monitoring

2. Meals and Nutritional Support

Rooms in stable, furnished homes with nutritious food options are provided as a core component. Three daily meals or regular meal access is included to ensure members are properly nourished during recovery — especially critical for those managing chronic conditions, recovering from surgery, or stabilizing on psychiatric medications where diet directly affects outcomes. HAMMOCK HOMES

3. Ongoing Health Monitoring

Ongoing monitoring of the individual's medical or behavioral health condition, including monitoring of vital signs, assessments, wound care, and medication monitoring, is a required minimum service. This includes: Partnershiphp

Regular wellness checks and vital sign monitoring

Medication reminders and oversight to ensure adherence to discharge prescriptions

Wound care support and dressing changes where applicable

Observation for signs of health deterioration requiring escalation to higher care

Documentation of health status for reporting back to the member's care team

4. Activities of Daily Living (ADL) Support

STPHH helps members gain or regain the ability to perform Activities of Daily Living. This may include support with: L.A. Care Health Plan

Personal hygiene — bathing, grooming, dressing

Mobility and safe transfers within the facility

Meal preparation assistance when needed

Basic housekeeping and laundry access

Orientation to the facility and its services

5. Case Management

Case management is central to STPHH and is what distinguishes it from simply providing shelter. Case management includes benefits access, behavioral health resources, and housing support to secure permanent shelter. Specifically, case managers: HAMMOCK HOMES

Assess the member's full set of needs upon admission

Help enroll members in SSI/SSP, Medi-Cal, CalFresh, and other income and benefit programs

Assist with obtaining vital documents such as IDs, birth certificates, and Social Security cards

Develop a housing plan focused on transitioning to permanent housing before discharge from STPHH

Connect members to Housing Transition Navigation Services to begin the search for permanent housing during the STPHH stay

Coordinate with the member's primary care provider, specialists, and behavioral health team

Identify and address barriers to permanent housing such as credit history, rental history, and documentation

6. Healthcare Coordination and Transportation

Collaboration with treating physicians and case managers, transportation to appointments, and updates to referral partners to prevent readmission are standard services. This includes: HAMMOCK HOMES

Scheduling and arranging transportation to follow-up medical, psychiatric, and substance use disorder appointments

Communicating with the discharging hospital or facility about the member's ongoing care needs

Warm handoffs to outpatient providers and specialty care

Coordination with the member's Medi-Cal Managed Care Plan and ECM Lead Care Manager

Referrals to behavioral health services, substance use disorder treatment, and mental health programs as needed

7. Connection to Permanent Housing Services

STPHH is explicitly designed as a bridge — not a destination. From the first day of a member's stay, STPHH providers are expected to actively work toward securing permanent housing before the stay ends. During their time in STPHH, members are connected to:

Housing Transition Navigation Services (HTNS) to identify and apply for permanent housing options

Housing Deposits to cover security deposit and move-in costs when a unit is secured

Transitional Rent (for eligible members) to cover up to six months of rent after moving into permanent housing

Housing Tenancy and Sustaining Services (HTSS) for long-term support to maintain tenancy after transition

The Coordinated Entry System (CES) — the local system that prioritizes the most vulnerable individuals for available permanent supportive housing and rental subsidies

✅ Who Is Eligible

To qualify for STPHH, a member must meet all of the following:

1. Must be exiting an institution. Qualifying institutions include recuperative care facilities (including facilities covered under Community Support Recuperative Care or other facilities outside of Medi-Cal), inpatient hospitals (either acute or psychiatric), residential substance use disorder treatment or recovery facilities, residential mental health treatment facilities, correctional facilities, nursing facilities, or recuperative care. L.A. Care Health Plan

2. Must be experiencing or at risk of homelessness, as defined by the HUD definition of homelessness under federal regulations — meaning the member lacks a fixed, regular, and adequate nighttime residence.

3. Must have ongoing physical or behavioral health needs. The member must have an ongoing physical or behavioral health need as determined by a qualified health professional that would otherwise require continued institutional care if not for receipt of STPHH. L.A. Care Health Plan

4. Must meet at least one additional clinical criterion. The member must also meet at least one of the following criteria: is receiving Enhanced Care Management; has one or more serious chronic conditions; has serious mental illness; or is at risk of institutionalization or requiring residential services as a result of a substance use disorder. HealthNet

5. Must be an active Medi-Cal managed care member enrolled in a plan that has contracted with an STPHH provider in the member's area.

🔑 Key Distinction: STPHH vs. Recuperative Care

STPHH and Recuperative Care (Medical Respite) are closely related but serve different levels of need. Understanding the distinction is important for appropriate placement:

Recuperative CareShort-Term Post-Hospitalization HousingClinical levelHigher — requires ongoing clinical monitoring, wound care, nursing supportLower — member is medically stable and cleared for dischargeMedical modelCan be clinical or non-clinical; more intensive oversightNon-clinical or light support; member can self-manage most health needsWho it servesMembers too sick for shelter, still needing medical recoveryMembers who are medically stable but have nowhere safe to goKey focusMedical recovery and treatmentHousing stability and transition to permanent housingCan receive both?Yes — members can move from Recuperative Care to STPHH as they stabilizeYes — STPHH can follow Recuperative Care as the member recovers

STPHH serves CalAIM members who are medically stable and cleared for discharge but lack safe housing. Participants must be able to self-manage medications and daily activities independently or with light support. HAMMOCK HOMES

⏱️ Duration and Global Cap

There is no longer a lifetime limit for STPHH. It is 182 days in a rolling 12-month period. Partnershiphp

STPHH and Recuperative Care are authorized under California's CalAIM waiver, and Transitional Rent is authorized under the BH-CONNECT waiver. These waivers establish a "global cap" on coverage. Under the cap, coverage is limited to six months of room and board services per member within a rolling 12-month period. This means that a member may not receive more than a combined six months of Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent during any rolling 12-month period. HealthNet

This global cap structure means that the three room-and-board services work together as a coordinated system:

RECUPERATIVE CARE + STPHH + TRANSITIONAL RENT = Maximum 182 combined days within any rolling 12 months

📊 Program Parameters at a Glance

ParameterDetailCost to member$0 — fully covered through Medi-CalMaximum durationUp to 182 days (6 months) per rolling 12-month periodGlobal capCombined STPHH + Recuperative Care + Transitional Rent cannot exceed 182 days per rolling 12-month periodEntry pointsHospital discharge, psychiatric facility discharge, SUD/mental health residential facility discharge, correctional facility release, recuperative care dischargeSettingNon-clinical residential facility — furnished, home-like environmentParticipationVoluntary — members may leave at any timeAvailable statewideThrough contracted MCPs in participating countiesFederal authority1115 waiver (distinct from the 1915(b) waiver covering most other Community Supports)

❌ What STPHH Does NOT Cover or Replace

STPHH cannot be used by members who still require a higher level of clinical care — those members should remain in Recuperative Care or an inpatient setting

STPHH does not cover permanent housing — it is explicitly a temporary bridge to permanent housing

STPHH cannot duplicate other state, local, or federally funded room and board programs

STPHH does not substitute for clinical treatment — it is a residential setting, not a clinical facility; ongoing clinical treatment must be coordinated separately

🔗 How STPHH Connects to the Full CalAIM Housing Continuum

STPHH sits at the critical post-discharge juncture of the care and housing continuum, and is most powerful when paired with other CalAIM services:

HOSPITAL / INSTITUTION / CORRECTIONAL FACILITY ↓ RECUPERATIVE CARE (if medically complex) [Up to 90 days — clinical recovery with medical oversight] ↓ SHORT-TERM POST-HOSPITALIZATION HOUSING ← You are here [Up to 182 days combined with RC — stable, supportive housing + case management + permanent housing planning] ↓ HOUSING TRANSITION NAVIGATION SERVICES [Active search and application for permanent housing] ↓ HOUSING DEPOSITS [Security deposit, utilities, and move-in essentials] ↓ TRANSITIONAL RENT (if eligible) [Up to 6 months of rental assistance] ↓ HOUSING TENANCY & SUSTAINING SERVICES [Long-term support to stay housed and prevent eviction]

📈 Why STPHH Matters — The Revolving Door Problem

Without STPHH, homeless individuals discharged from hospitals face an impossible situation. They return to the streets, encampments, or emergency shelters where they cannot rest, cannot safely store or take medications, cannot follow dietary restrictions, and are often re-exposed to the very conditions — injury, extreme weather, violence, substance use — that hospitalized them in the first place. Research from health foundations and state programs shows that high-quality medical respite and post-hospitalization housing reduces readmissions, supports faster healing, and provides essential connections to outpatient care and social services. HAMMOCK HOMES

The data is stark: without safe recovery housing, homeless individuals return to emergency departments within days or weeks of discharge, creating a costly and inhumane revolving door. STPHH addresses the root cause by providing the stability and support needed for genuine recovery while simultaneously building a pathway out of homelessness through intensive case management and permanent housing coordination.

How to Access STPHH

Referrals to STPHH can come from:

Hospital discharge planners and social workers — the most common referral source, often initiating the referral before the member leaves the hospital

Emergency department staff identifying members who are medically cleared but have nowhere to go

Recuperative care facilities discharging members who have recovered clinically but still need housing support

Correctional facility discharge coordinators for members releasing from jail or prison

Psychiatric and SUD residential treatment facilities upon discharge

ECM Lead Care Managers coordinating care for homeless members

Members or their families through self-referral to their Medi-Cal Managed Care Plan