Bridge to Care - Enhanced Care Management (ECM) Program
Referral Form
Date of referral
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Month
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Day
Year
Date
Individual Being Referred
Name
*
First Name
Last Name
Date of birth
*
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Month
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Day
Year
Phone number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Living situation
Lives alone
Lives with family
Lives with friends
Assisted living
Unsheltered
Other
If other, please specify
Gender identity
Please Select
Male
Female
Nonbinary/Gender diverse
Transgender male
Transgender female
Other
Prefer not to say
Preferred pronouns
Please Select
he/him
she/her
they/them
Preferred language
Interpreter needed?
*
Yes
No
Unknown
Medi-Cal Managed Care Plan (MCP)
*
Blue Shield Promise Health Plan
Molina Healthcare
Kaiser Permanente
Other
Unknown
If other, please specify
Medi-Cal Benefits Identification Card (BIC) ID Number
This is a 14-character alphanumeric code printed on the front of the BIC. This information is necessary to determine eligibility. If you do not have access to your BIC, you can obtain it by calling the local San Diego Medi-Cal phone number: (866) 262-9881
Attach BIC here
Browse Files
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Referring Party Information
Name
*
First Name
Last Name
Relationship to individual being referred
*
Please Select
Medical Provider
Behavioral Health Provider
Community Support Provider
Self
Family Member
Other Representative
Organization
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Area(s) of Concern
Eligibility for ECM requires that the individual meet at least one of the following categories. Select one or more category within the "Adults" area or "Children & Youth" area but not both. Within each category, additional criteria may apply. Checking one or more boxes will help determine initial eligibility for ECM. If you select an option in error, simply unselect it.
Adults (21 years and older):
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Experiencing homelessness (without dependent children/youth living with them) and have at least one complex health need
At risk for avoidable hospital or emergency department utilization
Serious mental health and/or substance use disorder needs
Living in the community and at risk for long-term care institutionalization due to unmet care needs and social/environmental challenges
Nursing facility resident transitioning to the community
Adults (21 years and older) Individuals Experiencing Homelessness (without dependent children/youth)
Experiencing homelessness AND
Have at least one complex physical, behavioral, or developmental need with inability to self-manage, where care coordination would likely improve health outcomes and/or reduce utilization of high-cost services.
Adults (21 years and older) Individuals at Risk for Avoidable Hospital or Emergency Department Utilization. Meet one or more:
5+ avoidable ER visits in a 6-month period, OR
3+ unplanned hospital and/or short-term SNF stays in a 6-month period.
Adults (21 years and older) Individuals with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
Eligible for SMHS (via MHP), DMC-ODS, or DMC program, AND
Experiencing at least one complex social factor influencing health, AND
Meet one or more:
High risk for institutionalization, overdose, or suicide
Use crisis, ED, urgent care, or inpatient services as primary source of care
2+ ED visits or 2+ hospitalizations in past 12 months due to MH/SUD
Pregnant or postpartum (within 12 months of delivery)
Adults (21 years and older) Living in the Community and At Risk for Long-Term Care (LTC) Institutionalization
Meet SNF level of care OR require lower-acuity skilled nursing, AND
Actively experiencing at least one complex social or environmental factor, AND
Able to remain in the community with wraparound supports.
Adult (21 years and older) Nursing Facility Residents Transitioning to the Community. Reside in a nursing facility but:
Interested in moving out, AND
Likely to transition successfully, AND
Able to reside continuously in the community.
Children & Youth (under 21 years):
*
Experiencing homelessness (unaccompanied children/youth and families)
At risk for avoidable hospital or emergency department utilization
Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS condition
Involved in child welfare
Children & Youth (under 21 years) Individuals Experiencing Homelessness (homeless families or unaccompanied children/youth)
Experiencing homelessness, OR
Sharing housing due to loss of housing, economic hardship, or similar reason, OR
Living in motels, hotels, trailer parks, or camping grounds due to lack of adequate alternatives, OR
Living in emergency or transitional shelters, OR
Abandoned in hospitals.
Children & Youth (under 21 years) Individuals at Risk for Avoidable Hospital or Emergency Department Utilization. Meet one or more:
3+ avoidable ED visits in a 12-month period, OR
2+ unplanned hospital and/or short-term SNF stays in a 12-month period
Children & Youth (under 21 years) Individuals with Serious Mental Health and/or SUD Needs. Eligible for one or more of the following:
SMHS delivered by MHPs
DMC-ODS
DMC program
Children & Youth (under 21 years) Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs
Enrolled in CCS or CCS WCM, AND
Experiencing at least one complex social factor influencing health.
Children & Youth (under 21 years) Involved in Child Welfare. Meet one or more:
Under 21 and currently in foster care in CA
Under 21 and previously in foster care in CA or another state within the past 12 months
Aged out of foster care up to age 26 in CA or another state
Under 18 and eligible for/in CA Adoption Assistance Program
Under 18 and currently receiving or have received services from CA Family Maintenance program within the past 12 months
Health Information
Medical Diagnosis(es) (if known)
Behavioral Health Diagnosis(es) (if known)
Include substance use disorder diagnosis(es)
Staff Use Only
1st outreach attempt:
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2nd outreach attempt:
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3rd outreach attempt:
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Date staff made contact with Member
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Outcome of call
Member was informed that MCP will determine eligibility
Yes
No
CPR was forwarded to FCHN
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Submit
Should be Empty: