Recovery Bridge Housing (RBH) is defined as a type of abstinence-based, peer

supported housing that combines a subsidy for recovery residences with concurrent treatment.


Recovery Bridge Housing Narrative


The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a new health care services

paradigm for Medi-Cal eligible individuals with substance use disorders (SUD). Los Angeles

County Department of Public Health Substance Abuse Prevention and Control (SAPC) will

implement an initial benefit package of SUD services within the initial 12 months of approval

from the California Department of Health Care Services (DHCS).

Recovery Bridge Housing (RBH) is defined by SAPC as a type of abstinence-based, peer

supported housing that combines a subsidy for recovery residences with concurrent treatment in

outpatient (OP), intensive outpatient (IOP), Opioid Treatment Program (OTP), or outpatient

withdrawal management (OP-WM) settings. RBH is often appropriate for individuals with

minimal risk with regard to acute intoxication/withdrawal potential, biomedical, and mental

health conditions. If there is risk potential, these concerns are to be managed by the treating

provider. The services provided in RBH vary, and include peer support, group and house

meetings, self-help, and life skills development, among other recovery-oriented services.

Treatment services cannot be provided in RBH.

Defined as an “optional” benefit under the Standard Terms and Conditions of the DMC-ODS

waiver, RBH is not a DMC reimbursable service. However, SAPC will conduct a pilot project to

explore offering RBH as a benefit within START-ODS to be funded via non-DMC funding and

inform future decisions about this benefit.


The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery

as “a process of change through which individuals improve their health and wellness, live a selfdirected

life, and strive to reach their full potential.” SAMHSA has also outlined four major

dimensions that support a life in recovery – health, home, purpose, and community.

According to the American Society of Addiction Medicine (ASAM) criteria, a comprehensive

SUD assessment should include the consideration of six dimensions in order to determine

appropriate level of care (LOC) placement for patients diagnosed with a SUD. Recovery/Living

Environment (Dimension 6) explores an individual’s recovery or living situation, and is one of

the six dimensions that should be factored into LOC decisions.

Importantly, a combination of risk factors in multiple ASAM dimensions contributes to

appropriate LOC placement, including residential treatment settings. Homelessness or lack of

safe, stable housing does not in and of itself mean that a patient would be appropriate for

placement in a residential treatment setting (American Society of Addiction Medicine 2013).

Research shows that SUD treatment outcomes are better for persons experiencing homelessness,

particularly chronic homelessness, when they are stably housed. RBH can provide a safe interim

living environment for patients undergoing OP/IOP/OTP/OP-WM treatment and also allows for

access to case management in a field-based setting which can help patients transition into

permanent housing and maintain their long-term recovery.

RBH aligns with the spirit of the ASAM criteria in the sense that individuals should be

appropriately placed in the least restrictive treatment environment necessary in order to meet

their clinical needs. While RBH is not officially an ASAM LOC, it serves as a bridge between

the more intensive and restrictive residential treatment setting and OP/IOP/OTP/OP-WM

treatment with no housing component attached. With the enhanced utilization controls of the

DMC-ODS, there will likely be a greater reliance on RBH as well as other housing options for

individuals in OP/IOP/OTP/OP-WM treatment settings who require recovery-oriented housing

while they receive SUD treatment.

Clinical experience and research support the notion that patients with SUDs need access to safe,

stable and supportive living environments to help them initiate and sustain their recovery and

reduce the risk of relapse. As more individuals access SUD treatment through the DMC-ODS,

the need to expand housing options to support individuals with their recovery is critical.

A continuum of housing options should be available to accommodate the varied needs and

preferences of patients. Some individuals may need short-term housing while they work to get

back on their feet, while others need access to permanent supportive housing. Within the

community, it is also important for those with SUDs to have access to both abstinence-focused

housing in RBH, as well as low barrier housing that is available in the community via the

Coordinated Entry System (CES) and does not require abstinence for those individuals who are

not yet ready or able to achieve abstinence.

The U.S. Department of Housing and Urban Development (HUD) defines Recovery Housing as

“housing in an abstinence-focused and peer-supported community for people recovering from

substance use issues” (United States Department of Housing and Urban Development 2016).

RBH, which provides an alcohol and drug-free living environment that supports an individual in

recovery from SUDs, is a type of Recovery Housing.

In Los Angeles County, subsidized RBH has traditionally been limited to certain populations,

specifically perinatal and criminal justice-involved individuals. The majority of available RBH

has been self-pay, requiring residents to pay for their own room and board. As such, there has

been limited accessibility to this service for low-income persons and individuals experiencing


In addition to the financial barriers, the intensity of the supportive services available to patients

in RBH settings has not always been sufficient to achieve and sustain recovery for many of those

experiencing homelessness, especially chronically homeless individuals with complex medical,

mental health and substance use conditions.

However, when paired with sufficient treatment and supportive services, and a complementary

continuum of housing options to meet the varied needs of the SUD population, RBH is a crucial

component to facilitate recovery.

Recovery Bridge Housing

The core goal of RBH is to provide a safe living space that is supportive of recovery for patients

who are receiving OP/IOP/OTP/OP-WM treatment for their SUD. Certain populations, such as

those experiencing homelessness, are particularly at risk for relapse without access to housing

and should be prioritized for this benefit. SAPC’s Foundational Principles of Recovery Bridge

Housing (see Table 1) are based on HUD’s characteristics of Recovery Housing as well as

recommendations from the California Department of Health Care Services around best practices.

Table 1.

Foundational Principles of Recovery Bridge Housing

1 Agencies managing RBH should not restrict access to this benefit to their own clients.

RBH beds should be available to any patient that is both eligible and appropriate for this

benefit within the SUD system of care and should belong to one of the groups prioritized

for this benefit.

2 Prioritization for RBH will be given to homeless adult patients including*:

- Perinatal patients (pregnant to 60 days postpartum)

- Active intravenous Drug Users (injected drugs within the last 30 days)

- High utilizer patients (as defined by high utilizer criteria for SAPC high tier care


- Chronically homeless (according to HUD definition2)

- Certain non-AB 109 criminal justice patients without alternative criminal justice

funding for recovery housing

- Transition Age Youth (TAY: “young adults” 18-25)

- HIV/AIDS patients

- Residential step down (homeless patients stepping down from residential treatment

into RBH)

1 SAPC high tier care management inclusion criteria: All individuals diagnosed with a SUD who meet any of the following


a. 3+ ED visits related to SUD within the past 12 months

b. 3+ inpatient admissions within the past 12 months for physical and/or mental health conditions and co-occurring SUD

c. Homelessness with SUD (as defined by HUD homelessness definition)

d. 3+ residential SUD treatment admissions within the past 12 months

e. 5 + incarcerations with SUD in 12 months

2 HUD definition of homelessness includes four categories: 1) Literally Homeless: individual or family who lives in a place not meant for human habitation or in an emergency shelter or is exiting an institution where (s)he has resided for 90 days or less andwho resided in an emergency shelter or place not meant for human habitation immediately before entering that institution; 2)

Imminent Risk of Homelessness: Individual or family who will imminently lose their primary nighttime residence within 14 days and who lacks the resources to obtain other permanent housing; 3) Homeless Under Other Statutes: includes unaccompanied youth under 25 or families with children and youth who have experienced persistent instability (see terms and definitions for more information); and 4) Fleeing/Attempting to Flee Domestic Violence: An individual or family attempting to flee DV who has no other residence and lacks the resources or support networks to obtain other permanent housing.

HUD definition of chronic homelessness is “a person must have a disability and have been living in a place not meant for human habitation, in an emergency shelter, or a safe haven for the last 12 months continuously or on at least four occasions in the last three years where those occasions cumulatively total at least 12 months” (United States Department of Housing and Urban

- Lesbian, gay, bisexual, transgender and questioning (LGBTQ) populations

* Populations other than the prioritized populations will only be authorized for RBH if

sufficient capacity is available to accommodate prioritized populations.

Note: Undocumented homeless adult patients who meet the prioritization criteria listed above are

eligible for placement in RBH.

3 Eligible participants should be medically and psychiatrically stable enough to benefit

from RBH.

4 Program participation is self-initiated and patient chooses abstinence-focused housing.

5 Program policies and operations should be consistent with the National Standards for

Cultural and Linguistically Appropriate Services (CLAS) and ensure individual rights of

privacy, dignity, respect and safety.

6 Programs should emphasize the personal recovery goals of participants and long-term

housing stability so as to minimize the likelihood of homelessness.

7 Program design should establish minimal barriers for entry into programs.

8 Program must meet or exceed National Alliance for Recovery Residence (NARR)

standards of care. (SAPC is in the process of developing RBH program standards of care

that will serve as the minimum standard once established).

9 Holistic services and peer-based supports are available to all program participants.

10 Relapse is not treated as an automatic cause for eviction from housing or termination

from the program.

11 Administrative discharge from housing should only occur under two conditions. First

when a participant’s behavior substantially disrupts or impacts the welfare of the

recovery community in which the participant resides, and secondly, if the participant is

no longer able to benefit from RBH due to becoming medically or psychiatrically

unstable. Participants may apply to reenter the program if they express a renewed

commitment to living in an abstinence-focused housing setting.

12 Participants who determine they are no longer interested in living in abstinence-based

housing or who are discharged from the program are offered assistance in accessing

other housing and service options.

13 Throughout the duration of program participation, programs are required to help patients

transition into permanent housing options to ensure a smooth transition once they are

ready to leave the program.

Assessing Patients for Placement in Housing

Before being admitted to treatment, all SUD patients will be assessed at the SUD treatment

facility site to which they have been referred on all six ASAM dimensions, including ASAM

dimension 6 – Recovery/Living Environment to determine level of care placement.

Patients who report they are homeless at intake should be assessed as soon as possible after they

are admitted to treatment using the Vulnerability Index-Service Prioritization Decision

Assistance Tool (VI-SPDAT) and immediately linked to a case manager to allow as much time

as possible for the case manager to help the patient find an appropriate housing placement. The

VI-SPDAT assesses and triages homeless individuals based on their health and behavioral health

needs to match them with appropriate housing and services, and is a necessary first step in order

to access housing options beyond the RBH that will be available within SAPC’s network, in

particular housing options through the Coordinated Entry System (CES) managed by the Los

Angeles Homeless Services Authority (LAHSA).

SUD providers should discuss and document housing preferences with patients, and combined

with their professional judgment, determine if housing in RBH – which requires abstinence from

drugs/alcohol and continued SUD treatment – or placement in other housing options outside of

SAPC’s network is more appropriate. If non-RBH is assessed to be more appropriate, SUD

providers should work with appropriate staff at CES lead agencies to match homeless individuals

with available housing for which they are eligible based on their VI-SPDAT score.

Who Can Provide Recovery Bridge Housing?

Because this is a new benefit in the SUD continuum of care, SAPC is piloting this benefit and

will be limiting RBH providers to current SAPC contracted providers with experience providing

recovery housing and who are in good standing and are on the Master Agreement list to provide

this service. RBH providers must be members of a recovery housing organization such as Sober

Living Network (SLN) or California Consortium of Addiction Programs and Professionals

(CCAPP) that adheres to NARR standards and best practices. RBH providers must enter into a

separate resident agreement with each individual placed in RBH.

Who is Eligible for SAPC Recovery Bridge Housing Subsidies?

SAPC may authorize RBH for adults who meet all of the following criteria:

1. In need of a stable, safe living environment in order to best support their recovery from a


2. Belongs to one of the prioritized populations listed in Table 1.

3. Concurrently enrolled in treatment in OP/IOP/OTP/OP-WM treatment settings.

RBH is intended for adult SUD patients who meet the criteria specified above. Individuals

appropriate for RBH may be stepping down from residential treatment, or may be entering the

SUD treatment system directly into OP/IOP/OTP/OP-WM levels of care. RBH for Transition

Age Youth (ages 18- 25) may also be available for eligible individuals who need a

developmentally and age appropriate living environment. Youth (under age 18) who require

recovery housing may be eligible for placement in a group home that provides treatment and

ancillary services in sites licensed by the California Department of Social Services.

Patients must be concurrently enrolled in OP/IOP/OTP/OP-WM treatment in order to receive

RBH subsidies. Those who are discharged from treatment in OP/IOP/OTP/OP-WM settings will

no longer be eligible to receive the subsidy for Recovery Bridge Housing.

Certain populations will be prioritized for RBH (see Table 1).SAPC will develop an electronic

prioritization system to facilitate RBH placement. Populations other than the prioritized

populations listed in Table 1 will only be authorized for RBH if sufficient capacity is available to

accommodate prioritized populations.

How Do Patients Get Placed in Recovery Bridge Housing?

People with SUDs have different needs with regard to the type of housing that best facilitates

their recovery. As a result, it is imperative that a broad continuum of housing be available to

provide individuals different housing options in order to best meet their unique recovery needs.

While some SUD patients prefer to live in abstinence-focused housing to help support their

recovery, others who are not yet ready or able to maintain abstinence prefer a low barrier, harm

reduction approach.

Individuals being considered for RBH should have chosen to be placed in an abstinence-based

living environment in order to facilitate their treatment and recovery. Subsequently, SUD

providers should discuss housing preferences with patients, and combined with their professional

judgment, determine if housing in RBH or placement in other housing options outside of SAPC’s

network is more appropriate.

All patients being considered for RBH should first be screened for alternative access to housing

through some other mechanisms (e.g. Probation provides access to recovery residences and other

housing options to AB 109 patients). Some individuals may be eligible for or receiving a

subsidy to pay for recovery housing from a funding source outside of the SUD system, such as

AB 109 funding. Since RBH cannot be paid for with DMC funds, SAPC network providers

should make every effort to match patients with appropriate recovery housing subsidized by

another funding source whenever possible.

If RBH is determined to be appropriate, SAPC providers must submit an authorization request

form and supporting documentation to the Quality Improvement / Utilization Management

(QI/UM) Unit in order to receive a subsidy for RBH from SAPC. Staff from the QI/UM Unit

will review the authorization request form and supporting documentation, and render a decision

on authorization of the RBH subsidy. Referring providers must document the need for RBH in

the patient’s treatment plan.

How Long Can a Patient Reside in Recovery Bridge Housing?

SAPC may authorize and subsidize up to a maximum of 90 days of RBH per calendar year for

patients who meet the eligibility criteria specified above. Individuals who do not utilize the

entirety of the 90 days during the year may use the remainder of the unused days later during the

calendar year, as necessary.

Perinatal patients may be eligible for lengths of stay in RBH up to the length of the pregnancy

and postpartum period, which is 60 days after the pregnancy ends based on medical necessity

(California Department of Health Care Services 2016).

What Are Some of the Expectations of SAPC Recovery Bridge Housing?

Operational Issues

- RBH providers must comply with all federal, state, city and county laws, rules and


- SAPC will provide monitoring and oversight of subsidized RBH in order to ensure

quality and adherence to all applicable rules and requirements and will conduct facility

inspections to ensure they are safe, sanitary and habitable.

- RBH providers are expected to meet or exceed standards consistent with the national

Standards of Care developed by NARR (SAPC is in the process of developing RBH

program standards of care that will serve as the minimum standard once established).

- RBH providers must maintain a naloxone kit for overdose prevention onsite and ensure

that House Managers or other designated staff receive training in administering naloxone.

- Single adult SUD patients are not allowed to reside in RBH with SUD patients who are

parents whose children are residing with them.

- Most RBHs are set up to serve a single gender. RBH providers should also have policies

and procedures to meet the needs of transgender patients.

RBH Admission Criteria

- Patients who receive RBH subsidies are expected to be abstinent from drugs and alcohol

and to be concurrently receiving treatment services in OP/IOP/OTP/OP-WM settings.

However, abstinence is not defined as including abstinence from medication-assisted

treatment (MAT). Patients placed in RBH may and should receive MAT, when clinically

indicated. RBH providers should have policies and procedures to ensure a clientcentered

process for when patients placed in RBH are receiving MAT.

- Patients receiving RBH subsidies must be screened for tuberculosis (TB) or provide

evidence of having been screened (e.g. for those stepping down from residential

treatment) within six (6) months prior to or thirty (30) days after admission into RBH.

RBH providers must have policies and protocols in place to address instances when

individuals screen positive for TB (e.g., procedures for referring individuals for necessary

TB treatment).


- To qualify for RBH, it must be defined as a service benefit that is integral to the person’s

overall recovery, and so specified in the treatment plan.

- If providers are requesting a subsidy to pay for RBH for a patient, they must submit an

authorization request and supporting documentation to SAPC’s Quality Improvement /

Utilization Management (QI/UM) Unit.

- Whenever possible and preferred by the patient, individuals should be placed in RBH that

is located within 1 hour travel time of their treatment provider.

Recovery-Oriented Services

- Whether individuals placed in RBH settings are stepping down from residential treatment

or entering the SUD treatment system into OP/IOP/OTP/OP-WM settings, counselors

should work with patients as soon as they enter treatment to develop a treatment and

transition plan that includes consideration of the recovery/living environment and a plan

for placement in appropriate housing. Placement in RBH and associated services should

emphasize the personal recovery goals of participants and long-term housing stability so

as to minimize the likelihood of homelessness.

- RBH providers should provide peer-based support services onsite, including house

meetings, self-help meetings, and other recovery-oriented services. RBH staff should also

encourage residents to participate in recovery-oriented activities when not engaged in

OP/IOP/OTP/OP-WM treatment activities or work.

- Treatment providers are encouraged to provide relapse/lapse support for patients in RBH,

and work with residents who have experienced relapse or lapse on an individual basis.

Relapse should not be treated as an automatic cause for eviction from RBH. Patients who

have experienced a brief lapse but who remain committed to recovery and willing to

reengage in treatment should be allowed to return to RBH or referred to another RBH

provider. RBH providers should have policies and procedures outlining their protocol for

handling relapses and lapses such as encouraging patients to discuss their relapse/lapse

with their current treatment provider.

- Patients who need or who choose a different type of housing support than RBH, such as

one which is not abstinence-focused, or who need a more intensive level of housing

support, such as permanent supportive housing, should be offered other housing referrals

(e.g. through the CES).

Discharging patients from Recovery Bridge Housing

OP/IOP/OTP/OP-WM providers should begin discharge planning for patients immediately once

they enter treatment. For RBH patients, this includes working with the patient to create a

housing plan for the patient when they are discharged from treatment and will no longer be

eligible to receive a subsidy to pay for their stay in a recovery residence.

Given the chronic and relapsing nature of SUDs, differentiating between a relapse and lapse may

help RBH providers decide when an individual can be appropriately maintained in an abstinencebased

housing environment and when another housing setting may better meet the needs of their


While a relapse can be defined as a prolonged episode of substance use during which the client

is not interested or open to a therapeutic intervention, a lapse can be defined as a brief return to

substance use following a sustained period of abstinence, despite the patient remaining

committed to recovery and demonstrating a willingness to re-engage with the recovery journey.

Relapses often warrant discharge due to negative impact on the health and safety of other RBH

residents. However, lapses often do not result in such impact and may be an opportunity to foster

therapeutic growth, both for the affected individual and the RBH community. As such, patients

should not be discharged from RBH solely because of a lapse, but rather should only be

considered for discharge in instances such as those discussed above, either when rule violations

jeopardize the operation of the RBH or the health and safety of its residents, or when the

participant is not in a position to benefit from this housing service. More detailed guidelines

regarding discharging patients from RBH will be included in the standards of care for RBH

being developed by SAPC.

Staffing for Recovery Bridge Housing

RBH providers are responsible for ensuring onsite house managers help oversee the day-to-day

operation of the facility, ensure adherence to policies and procedures, rules and requirements,

and be responsible for ensuring the quality of the facility and the health and safety of residents.

Providers will be required to provide SAPC with a protocol describing how they will address any

health and safety issues that may arise. It is recommended that RBH house managers be certified

peer specialists to ensure that they have training in peer supported services.

All staff, including clerical, billing and facility management support, shall receive appropriate

onsite orientation and training prior to performing assigned duties. All staff are required to have

appropriate experience and necessary training at the time of hiring, and should be familiar with

confidentiality regulations under 42 Code of Federal Regulations (CFR) Part 2 governing the

confidentiality of substance use disorder patient records.

Final Note:

SUD treatment should be delivered across a continuum of services that reflects the severity of

the condition and the intensity of services required. One of the key goals of SAPC is to ensure

that clients receiving SUD services in Los Angeles County receive the right service, at the right

time, for the right duration, in the right setting. While the levels of care are presented as discrete

hierarchies, they should be viewed as points along a continuum of treatment services.


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