Who is eligible for HRSN housing services?

Individuals must meet the following criteria to be eligible for housing transition navigation and rent/temporary housing services:

• Enrolled in Apple Health (Medicaid)
• Homeless or at risk of homelessness, as defined by 24 Code of Federal Regulations (CFR) 91.5
• Have complex behavioral health, co-occurring substance use needs among others, disability requiring assistance, or other long-term care needs

For questions and information about specific program eligibility, please refer to program-specific information on this page.

HRSN housing transition navigation services under MTP 2.0

These services aim to remove barriers to affordable housing, including transition costs and housing deposits to assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to help a person establish a basic household.

• Transition Assistance Program (TAP)
  The state will leverage the existing TAP to administer housing transition navigation services to enrollees of the FCS Supportive Housing program. For more information on TAP, please see the TAP program overview document or visit the FCS Supportive Housing page.

HRSN rent/temporary housing services under MTP 2.0

These services provide stable, independent living situations for individuals transitioning out of institutional care or congregate settings who are homeless or at risk of homelessness. Payment may cover rent and/or short-term temporary stays for up to six months. These services will be implemented statewide for eligible individuals through the FCS program, Apple Health and Homes, and Home and Community Services.

• Rent and temporary housing under Foundational Community Supports (FCS)
  Rental assistance payments will be made on behalf of eligible recipients in the FCS Supportive Housing program through the Spokane Housing Authority.

• Rent and temporary housing with Apple Health and Homes (AHAH)
  AHAH is a multi-agency effort that pairs housing resources (capital financing and rental/operations assistance) with supportive services through the FCS program. HRSN funds will be used for up to six months of rental assistance for eligible AHAH recipients. Rent will be paid directly to landlords on behalf of tenants by the Department of Commerce’s Office of Apple Health and Homes.

• Rent and temporary housing with Home and Community Services (HCS) through the Office of Housing and Employment (OHAE)
  • OHAE teams work to increase access to permanent, affordable housing and employment opportunities. They ensure services and supports are available and used to help maintain one's housing and employment, while also honoring client choice, preference, and need. 
  • HCS is expanding access for rent assistance programs, including Emergency Rental Assistance, Interim Housing, and temporary rent for HCS FCS Supportive Housing clients, for HCS HRSN-eligible individuals.

Provider information

This section links to additional information about providers that offer MTP 2.0 HRSN housing services.

• Foundational Community Supports (FCS)
  The FCS provider network is made up of over 150 agencies, including behavioral health providers, substance use disorder providers, Tribal partner providers, nonprofits, and housing authorities. FCS services are available at more than 400 sites statewide.
  • View the provider map
  • Learn how to become an FCS provider
• Home and Community Services (HCS)
  • Provider network: Counties with provider availability
  • How to become an HCS rent/temporary housing provider: Learn more about contracting with DSHS

Program contact information

Additional information and contact details for each HRSN housing services program is listed below.

• Foundational Community Supports (FCS)
  • Email: FCS team
  • For questions about FCS eligibility, contact Wellpoint
  • Visit: FCS page
• Apple Health and Home (AHAH)
  • Email: Anessa Williams
  • For questions on AHAH eligibility, contact Wellpoint
  • Call: 844-451-2828
  • Visit: AHAH page
• Home and Community Services (HCS)
  • Email: Whitney Howard
  • For questions on eligibility, contact your local HCS office
  • Visit: HCS page

What is the HRSN screening and referrals service?

HRSN screening and referrals refer to screening, referral, and coordination of health-related social needs services and community resources for individuals to improve and manage their health. Community Care Hub providers work closely with a large network of community partners, community-based organizations (CBOs), and community-based worker/workforce (CBWs) in their region.

HRSN screening and referrals include the following activities

• Establish a network of providers, community partners, and community-based organizations that deliver waiver-funded HRSN services and non-waiver HRSN services of community supports services
• Identify and engage Apple Health clients who are likely to have multiple health and social needs by working closely with managed care organizations (MCOs), providers, and community partners
• Screen client's health and/or health-related social needs (if not already screened by MCOs or providers)
• Check client's eligibility to receive either waiver-funded HRSN service of non-waiver community supports or resources
• Refer clients to providers, community partners, or organization(s) that will address their HRSNs
• Follow-up to ensure clients are connected to services and that interventions are completed
• Track outcomes of clients' receiving services
• Provide technical assistance and capacity support - including infrastructure dollars - to community partners or CBOs that deliver waiver-funded HRSN services, and to their community-based workforce
• Provide navigation assistance through a local, trusted community-based workforce

How can someone receive an HRSN screening and referral?

Navigating the process for accessing HRSN services can be challenging. To ensure that individuals and families receive the support they need, there are several paths for referrals to your local Community Care Hub:

• Direct referrals: These referrals are typically made by healthcare providers, social workers, or community organizations who identify an individuals’ specific needs.
• Community-based organizations referrals: local community organizations can play a role in connecting individuals to the Community Care Hubs and HRSN services.
• Managed care organizations (MCOs) referrals: MCOs frequently serve as key referral pathways for HRSN services.

Additionally, individuals can self-refer if you are in need of HRSN services. Please see the Community Care Hub Referral Pathways flyer for additional information and contact details for each of the nine regional Community Care Hubs.

What are Community Care Hubs?

Community Care Hubs (CCHs), established by Accountable Communities of Health (ACHs), are the only entities that can provide the HRSN screening and referral service.

There are nine regional CCHs across Washington State – each function as a central source for connecting individuals with health-related social needs to appropriate services to address these needs within their region. Under the HRSN screening and referral service, CCHs coordinate HRSN referrals by working closely with community organizations, social service, health care facilities, correctional institutions, and governmental bodies. Trained community-based workers (CBW) provide the screening and referral service.

Along with the nine CCHs, Washington State also has one statewide Native Hub. The Native Hub is a statewide network of Washington Tribes, Indian Health Care Providers (IHCPs), tribal social care service divisions, and Native-led, Native-serving organizations in service to whole-person care coordination.

What are Accountable Communities of Health?

Community Care Hubs were developed by Washington State's Accountable Communities of Health (ACHs). More information can be found on the MTP Accountable Communities of Health webpage.