Introduction to Housing Stabilization Services

Housing Stabilization Services were introduced as a Medicaid-billable healthcare service in July of 2020, with these stated goals:

• Support an individual's transition into housing,
• Increase long-term stability in housing in the community, and
• Avoid future periods of homelessness or institutionalization.

These services include:

• Consultation: helping an individual develsoped a person-centered housing plan.
• Transition: supports to help a person find, apply for, and find financial and other resources for moving into a new home.
• and
• Sustaining: supports to help a person maintain living in their home in the community.

Each of these services are explained in more detail below.

Eligibility and Referrals

Eligibility for Housing Stabilization Services is defined in more detail in the Minnesota Health Care Programs Manual here, but consists of essentially these three qualifying factors.

Eligible recipients are:

• Adults with Medical Assistance (including PMAPs) who are elderly, blind or disabled;
• Who require assistance with communication, mobility, decision-making, or managing challenging behaviors; and
• Who are homeless, at risk of homelessness, or at risk of institutionalization., or currently transitioning, or recently transitioned, from an institution or licensed or registered setting.

Eligibiility Requests

Clinicians, Practitioners, Integrated Care Managers (CMGT & BHH), and outside parties may making a referral identifying which of the three services the indivdiual needs to one of our Housing Consultants.

The Housing Consultant will begin the process by revewing eligibility. We must be confident that they meet the criteria above. If you are the Consultant asked to start this process and have questions, seek guidance first.

The next step is to complete the Housing-Focused Person-Centered Plan first, to submit along with the eligibility request:

Key Questions on the HFPCP

These three questions are the heart of the Housing-Focused Person-Centered Plan and must be answer as described below:

1) CHECK ONE OR MORE ASSESSED NEEDS (MUST REFLECT THE NEED AREAS THAT WERE IDENTIFIED IN THE ASSESSMENT)

_Mobility _Communication _Decision making _Managing challenging behaviors

2) AREAS IN NEED OF HOUSING

How will the areas of assessed need be reflected in the person's housing? Please write at least 3-4 sentences explaining how the person's needs (mobility, communication, decision making, or managing challenging behaviors) affect their ability to find or keep housing.

*This must specifically describe how the checked items above are barriers to housing.

3) SUPPORT INSTRUCTIONS

What will the provider do to address the recipient's assessed need(s) related to housing? Please write at least 3-4 sentences explaining how the provider will support the person with their assessed needs and help them find/keep their housing; as well as identify if they are starting with transition or sustaining services.

*This must specifically describe how supports will address the checked items above.

Next Steps

Work can also begin on the eligbility request:

The Eligibility Request must be accompanied by one of the following:

Preferred, the Coordinated Entry Assessment that can be obtained after completing a:

or, one of the following:

or

or

After completing the required documents, notiify the Service Coordinator, who will enter the SPDAT into the Coordinated Entry Assessment online and submit the eligibility rquest to DHS for review and approval. Services should not begin until approval is obtained. Reviewing eligiblity prior to starting this process is essential, as we may not bill for development of the Plan if the eligiblity request is denied.

Managing Referral-to-Service

Step	Action
Referred individual has either a Care Coordinator with their MCO, or a Waiver (CADI, TBI, etc.) Case Manager.	Mark the individual's status for HSS as Referral and ask the Care Coordinator or Waiver Case Manager to submit an eligigibilty request for Housing Stabilization Services (or confirm that they have done so). Request a copy of the eligibility request and Housing-Focused Person-Centered Plan with a signed ROI from the referred individual. *Possibly, completing our full SPDAT and HSS Eligibility Request and sending to the Care Coordinator or Case Manager may help expedite this process. Check back here again for details.
Referred individual does not have a Care Coordinator with their MCO, or a Waiver (CADI, TBI, etc.) Case Manager.	Mark the individual's status for HSS as Referral and begin the Assessment called SPDAT and HSS Eligibility Request (Family or Individual), found in Eligibility Assessments and Requests. This document includes the elements necessary for the - SPDAT (Service Prioritization Decision Assistance Tool), and - Housing-Focused Person-Centered Plan
The Eligibility Request and Housing-Focused Persons-Centered Plan has been submitted.	Mark the individual's status for HSS to Initiating. Record the subission using the Administrative Support service type: Auth Request or Notification Sent
The Eligibility Request and Housing-Focused Persons-Centered Plan has been approved.	Mark the individual's status for HSS to Active and begin services by: 1) Entering Goals and Objectives for housing into the client's file, 2) Building a Tabs Service Plan 3) Scheduling the Transitioning or Sustaining service.
Instructions for building the Tabs Housing Stabilization Services Plan.	If the individual currently receives other services and the Plan for those services is due within the next 30 days, update that plan, adding HSS services. Use the custom template Treatment Plan Addendum to add the HSS service, goals and objectives.

Housing Consultation

Housing Consultation consists solely of developed the Housing-Focused Person-Centered Plan. Described in more detail in the DHS Housing Stablization Services page here, this includes:

• Developing a housing focused person-centered plan based on desired outcomes
• Completing the eligibiility request
• Supporting the person in identifying their strengths, needs and wants in housing including cultural requirements and/or preferences
• Supporting the person to make an informed choice in their housing transition/sustaining provider
• Offering resource information for services that support non-housing related goals as identified in the person centered planning process
• Coordinating with other service providers currently working with the person
• Helping the person understand their rights to privacy and appeal information
• Annually reassessing the person-centered plan as it relates to housing

Developing this plan is billable as Housing Consultation for adults who are not recipients of Adult Mental Health Targeted Case Management at Accend. When we are providing Case Management, developing this plan is a Case Management service and not separately billable.

Housing Consultation should be done by a Waiver Case Manager or MSHO/Care Coordinator if the client has either of those services already provided.

Documenting Completion of the Housing Focused Person-Centered Plan

For clients who are not Case Managment clients, document work on the Housing Plan as Housing Consultation. Use the meeting types Face-to-Face for the interview and Non-Face-to-Face for the write-up work.

When the plan is complete and sent to medical records for submission, use the add-on "Housing Plan Complete".

Housing Transition

Transition services consist of:

• Developing a housing transition plan*
• Supporting the person in applying for benefits to afford their housing, including helping the person determine which benefits they may be eligible for*
• Assisting the person with the housing search and application process*
• Assisting the person with tenant screening and housing assessments*
• Providing transportation with the person receiving services present and discussing housing related issues
• Helping the person understand and develop a budget
• Helping the person understand and negotiate a lease
• Helping the person meet and build a relationship with a prospective landlord
• Promoting/supporting cultural practice needs and understandings with prospective landlords, property managers*
• Helping the person find funding for deposits*
• Helping the person organize their move*
• Researching possible housing options for the person*
• Contacting possible housing options for the person*
• Identifying resources to pay for deposits or home goods *
• Identifying resources to cover moving expenses*
• Completing housing applications on behalf of the service recipient*
• Working to expunge records or access reasonable accommodations*
• Identifying services and benefits that will support the person with housing instability*
• Ensuring the new living arrangement is safe for the person and ready for move-in*
• Arranging for adaptive house related accommodations required by the person*
• Arranging for assistive technology required by the person*

Activities with an asterisk (*) can be provided directly (in person) or indirectly on behalf of the person. The expectation is that services are primarily provided as a direct service. Your progress notes must indicate whether the service was provided in person or as an indirect service using the service type.

Sustaining Housing

Sustaining services include:

• Developing, updating and modifying the housing support and crisis/safety plan on a regular basis
• Preventing and early identification of behaviors that may jeopardize continued housing
• Educating and training on roles, rights, and responsibilities of the tenant and property manager
• Transportation with the person receiving services present and discussing housing related issues
• Promoting/supporting cultural practice needs and understandings with landlords, property managers and neighbors*
• Coaching to develop and maintain key relationships with property managers and neighbors
• Advocating with community resources to prevent eviction when housing is at risk and maintain person’s safety*
• Assistance with the housing recertification processes*
• Providing in-service transportation (person must be with)
• Continued training on being a good tenant, lease compliance, and household management
• Supporting the person to apply for benefits to retain housing*
• Supporting the person to understand and maintain/increase income and benefits to retain housing*
• Supporting the building of natural housing supports and resources in the community including building supports and resources related to a person’s culture and identity
• Working with property manager or landlord to promote housing retention*
• Arranging for assistive technology*
• Arranging for adaptive house related accommodations.*

As for transitioning, sustaining activities with an asterisk (*) can be provided directly (in person) or indirectly on behalf of the person. The expectation is that services are primarily provided as a direct service. Your progress notes must indicate whether the service was provided in person or as an indirect service using the service type.

Moving Expenses

Moving Expenses is a benefit available for recipients of Housing Stabilization services. This benefit includes reimburse for a variety of expenses related to moving and is limited to certain types of moves (type of current housing and new housing. This benefit is available one-time only as is limited to a total of $3000. This section will summarize, but you may have questions and should ask before promising this benefit to your clients.

Eligibility

To be eligible for Moving Expenses, an individual must be making the one of the following (Transitioning) types of moves:

• Moving from a Medicaid funded institutional setting to community housing (examples, Nursing Facilities, Hospitals, Intermediate Care Facilities for persons with developmental disabilities, Resident Treatment Facilities and Institutions).
• Currently homeless and has stayed in a shelter or county-funded emergency shelter (including hotel voucher program or other county-funded emergency housing sites) at some point over the last 12 months.
• Leaving a housing with supports environment or housing with services environment for independent housing.

Not eligible are moves such as the following:

• Independent housing to other housing of any kind
• Supported housing to other supported housing
• Other lateral moves

Allowed Types of Expenses

Moving expenses may include the following:

• Applications, security deposits, and the cost of securing documentation that is required to obtain a lease on an apartment or home
• Essential household furnishings required to occupy a person’s home, including furniture, window coverings, food preparation items, and bed and bath linens
• One-time set-up fees or deposits for utility or service access, including telephone, electricity, heating, and water
• Necessary home accessibility adaptations such as grab bars in the bathroom, doorbells that blink, sound alerts, alarms on doors, entryway ramps, etc.
• Services necessary for the individual’s health and safety, such as pest eradication and one-time cleaning before occupancy
• Moving services

Moving expenses are described here (tap on moving expenses and then the link under the heading What is covered under Moving Expenses? for a long, but not exhaustive list.

Non-eligible expenses include, but are not necessarily limited to:

• Rent and mortgage payments
• Food
• Clothing
• Recreational items such as streaming devices, computers, televisions, cable television access, cell phones, and similar.

Procedures and Authorization

1. Before Moving Expenses can be requested, they must be authorized by DHS. This can occur as a part of the original HSS eligibility request or with an amended request.
2. Housing Transition staff will develop a budget and request.
3. The HSS Supervisor will review the request and submit to administration for approval. This must occur before any purchases are made.
• Online purchases will be prepared by the Office Manager.
• Where services such as environment modifications, moving services, pest eradication, etc. are needed, a request in the form of an estimate is required. Obtain this from the vendor and submit for approval.
• Services such as pest eradication and cleaning for a move to rental housing are the responsibility of the landlord. These expenses will be approved only for individuals purchasing housing.

*HSS staff should NEVER make purchases with their own money and then request reimbursement.

Receipts and Documentation

Obtain receipts for all purchases. For sellers/vendors who do not provide their own receipts, obtain their signature on this one. Upload all receipts to the client's documents in Tabs.

Log all purchases using the Tabs form "Moving Expenses Log" in the client's file (found at document>client forms>client expenses>Moving Expenses Log).

Send receipts for all purchases to Medical Records, who will upload them to the client file and forward them to billing.

Physically Moving Clients Is Not a Service We Provide

See the Staff Health and Safety Guide for the policy that disallows this.

Initiating Housing Stablization Services

When initiaing HSS services for current clients who already have an Integrated Plan in place, use the stand-alone HSS Service Plan. Set the end date for the plan to match the end date of the current Integrated Plan, at which time the plans should be integrated.

If HSS services are recommended at the outset of services, or coincide with a subsequent update, simply integrate all plans immediately.

Docmenting Housing Stablization Services

Service Type	Use	Special Instructions
Housing Consultation	All activities associated with interviewing the individual and developing the plan. Use the meeting type Face-to-Face for the Interview, and non-Face-to=Face for other activities associated with developing the plan.	These activities are not separately billable. Total time to interview and write a single individual's plan should not exceed 4 hours. Please note, as describe above, this is not a separely billable service for clients of AMH-TCM. It is done as a part of AMH-TCM services.
Housing Transition Supports	Transition services. Use the meeting type to indicate whether or the not services were Face-to-Face or Non-Face-to-Face.	Billed in 15-minute units. Start and end time required. Notes must describe specific activities listed above. In-service transportation (Travel During) is allowed.
Housing Sustaining Supports	Sustaining services. Use the meeting type to indicate whether or the not services were Face-to-Face or Non-Face-to-Face.	Billed in 15-minute units. Start and end time required. Notes must describe specific activities listed above. In-service transportation (Travel During) is allowed.
HSS Client Initiated Cancellation	Client cancels a face-to-face session.	Use time during cancellations to complete other follow-up or investigative work needed for that client or others.
HSS Contact and Scheduling	Efforts to contact a client for a face-to-face session.	Describ efforts to contact and reschedule in the note.
HSS Coordination of Services	Coordination of Services. Use the meeting type Internal or External.	Do not use External Coordinaiton when the activity meets criteria for Non-Face-to-Face services indicated with an asterisk above.
HSS Provider Initiated Cancellation	Provider cancels a face-to-face session.	Describe resceduling efforts in the note.

Discharge

Discharge reasons and procedures for each are as folllows.

Voluntary Discharge or Transfer to Another Provider

When an individual receiving Housing Stabilization Services wishes to discharge or transfer to another provider, complete form DHS 8110. This simple form requires only a checkbox indicating the desire to discharge, and the signature of the recipient and provider, name, and date.

Loss of Eligibility or Permanent Loss of Health Care Coverage

Eligibility

As a result of a subsequent Consultation, the individual may be:

• deemed no longer eligible by the Housing Consultant (in consultation with a supervisor)*, or
• denied eligibility for continuing services when a subsequent Housing-Focused Person-Centered Plan is submitted to DHS for review.

*Review eligibility requirements here thoughfully with determining eligibility.

When discharging for either reason, inform the recipient of their rights to appeal the decision. No formal appeal process is described in current available materials. Check back again for updates to this section.

Permanent Loss of Health Care Coverage

Housing Stabilization Services require that the individual is enrolled in Medical Assistance (straight MA or through and MCO). If a recipient permanently loses eligibility for this health care coverage (example, obtains private insurance or no longer otherwise qualifies) discharge will occur. Individuals may also appeal determinations of elibility for MA.

Disengagement

Disengagement means lack of participation in the service as characterized by:

• Repeated, consecutive cancellations or no-shows over a period of two months,
• Being out of contact for a period of 2 months.

When discharging for disengagment, follow these steps:

1. Make and document at least weekly efforts to contact the individual     .
2. Contact other providers for whom you have signed Releases of Information in an effort to determine the individual's whereabouts.
3. Debrief on the case during your next scheduled monthly supervision and document the debriefing in a File Note.
4. After two months, if the individual is not engaged with any other services, send a We've Been Missing You letter to the individual's last known address inviting the individual to contact us.
5. Change the individual's status for this service to Closing.
6. Hearing nothing, complete a Discharge Review and change status to Previous.

Moving Out of State

A person can receive transition services to find housing, including visiting properties, in local trade areas (areas near Minnesota a person may drive to for goods and services) in another state. If a person is moving to another state outside of a local trade area, transition services can still be provided with the exception of visiting properties with services again ending when the person moves.

Once the person moves to the other state, they would no longer be on MN Medicaid and are no longer able to receive Housing Stabilization Services.

Other

Rarely, we may determine that is is not safe, feasible, or appropriate to provide services to an individual. When making this determination, assist the individual with a referral to another provider and provide the Housing-Focused Person-Centered Plan to that provider.

Provider Qualifications

To qualify as one of our Consultation, Transition or Sustaining providers, you must:

• Complete mandated reporter training, which includes training on vulnerable adult law.
• Pass a criminal background check.
• Be knowledgeable of local housing resources.
• Housing Consultation services providers must complete mandated Housing Consultation training on TrainLink (HSS100). You will need a unique key to take this training.
• Housing Transition and Housing Sustaining services providers must complete mandated Housing Transition and Housing Sustaining training on TrainLink. You will need a unique key to take this training.
• All staff working directly with Housing Stabilization Services recipients must complete Housing Consultation, Housing Transition and Housing Sustaining training (HSS200). You will need a unique key to take this training.
• Housing stabilization providers need to follow Home and community-based services requirements. Review the Home and community-based services providers webpage for additional information.

Competencies for Housing Stabilization Providers

All of these topics are available on the Trainlink website..

Navigate to the Trainlink website. Log in using your unique key. Navigate to Housing and Supports Services. Search using the keyword "housing" to find these courses:

Course Number	Course Name	Who Should Complete
HSS100	HOUSING CONSULTANT TRAINING FOR HOUSING STABILIZATION SERVICES	Consultants
TCM100	TCM: INTRO TO THE HOUSING FOCUSED PERSON-CENTERED PLAN	Case Managers
HSS200	TRANSITION & SUSTAINING PROVIDER TRAINING FOR HOUSING STABILIZATION SERVICES	Transitioning and Sustaining Providers
HSS200.9	2024 MOVING EXPENSES MODULE FOR HOUSING STABILIZATION SERVICES	All HSS Staff

Additionally, read the following:

• > HCBS Rights Modification Support Plan Guide for Housing Stabilization Services - April 2021 (PDF)
• > Helpful Tips for Housing Stabilization Services Eligibility Requests (PDF) - July 2021
• > Information for Targeted Case Managers (PDF) - September 2020
• > Allowable Documentation for Eligibility Requests - June 2021 (PDF)
>Housing Stabilization Services Provider Training (PDF) - June 2020

Housing Stabilization Consultants

Basics

1. Identify how a person is determined eligible for HSS
2. Describe the three types of services offered by this program

HB101 Paths

3. Set up an professional account with a user login on HB101
4. Request a Professional HB101 role
5. Use Vaults Files and Contacts Tabs
6. Use the Pro Files and Contacts in the Vault
7. Complete a housing needs assessment with a recipient using the functions of “Paths” on HB101
8. Help an individual obtain all required documents for an eligibility review
9. Write a housing focused person-centered plan

Complete and Submit Eligibility and Authorization Forms

10. Use the MN-ITS provider look up function to verify a person’s eligibility information related to these services
11. Locate and access the DHS Eligibility Request form (DHS-7948) through the e-docs directory Determine the eligibility documents and assessment information required to submit the form
12. Complete the notification process that occurs after the eligibility form has been submitted

Find Me a Home: Transitioning Services

Budget and Resource Options

1. Explore a persons housing budget options using HB101 vault tool
2. Identify the resources and tools provided by HB101 that help a person make informed choices about their housing
3. Assist with the housing search and application process and securing additional services, benefits and resources to support housing
4. Help individuals complete applications for programs that may increase their ability to afford housing
5. Identify and resolve barriers to accessing housing, including resources to cover moving expenses, deposits, application fees
6. Develop a housing services plan based on a person’s needs, wants, budget and their person-centered plan.

Finding Housing

7. Identify the types of housing options available to a person based on your knowledge of local housing resources and tools.
8. Recognize the types of housing that someone can move into based on the Home and Community Base Services (HCBS) requirements.
9. Determine other housing related services a person is on to determine budgeting options and to prevent duplication.

Move In

10. Help a recipient organize their move and ensure the new living arrangement is safe and ready for move-in
11. Successfully move recipients into their new home

Keep Me in My Home: Sustaining Services

Building Relationships and Solving Problems

12. Help people build relationships with landlords, neighbors, and roommates in order to remain stably housed and resolve potential problems
13. Help people know and understand their rights as tenants
14. Help people identify other benefits for which they may be eligible when encountering difficulty or barriers to sustaining housing

Eviction/Ending a Lease

15. Help people avoid an eviction, and recognize the importance of keeping an eviction off someone’s record
16. Understand that if the eviction is due to a person’s disability they should check to see if there is a reasonable accommodation that will keep the landlord from filing in court
17. Help people end or change a lease and move out of housing
18. Help people who are facing an eviction to find an acceptable resolution (that can include finding other housing)

Resources and References

Tap on any of the following links to learn more.

Feedback or Questions about this Chapter

This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Want to volunteer to become a provider of HSS? Please send us your thoughts about anything in this chapter by tapping on the link below.

Updates to this Chapter

---

April 10, 2023: Discharge procedures added.

---

April 21, 2023:Referral to Admission instructions addded.

---

Sept 4, 2024:Moving Expenses

Brief explanation added for how to internally handle and foward receipts for moving expenses.

---

Language added, cross-referencing Staff Health and Safety Guide, reminding that physically moving clients is not a service we provide.

---