Bridge to Care - Enhanced Care Management (ECM) Program

Bridge to Care - Enhanced Care Management (ECM) Program

Referral Form
Date of referral

MonthDayYear
Date
Referral source*
If other representative, please specify
Contact person*

First NameLast Name
Contact person's phone number*
Please enter a valid phone number.
Contact person's email
example@example.com
Person Being Referred
Name*

First NameLast Name
Phone number
Please enter a valid phone number.
Email
example@example.com
Date of birth

MonthDayYear
Age
Gender
Preferred pronouns
Is the individual a resident of San Diego County?*

YesNoUnknown
Insurance/Payor Information
Is the individual a Medi-Cal beneficiary?*

YesNoUnknown
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:

Cancelof
Managed Care Plan (MCP) / Health Plan*

Blue Shield Promise Health PlanMolina HealthcareKaiser PermanenteOtherUnknown
If other, please specify:
IF THE INDIVIDUAL IS NOT A SAN DIEGO COUNTY RESIDENT AND A MEDI-CAL BENEFICIARY, STOP. THIS INDIVIDUAL IS NOT ELIGIBLE TO PARTICPATE IN FUNDAMENTAL HEALTH’S BRIDGE TO CARE PROGRAM.
Living situation

Lives aloneLives with familyLives with friendsAssisted livingUnshelteredOther
If other, please specify:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred language
Interpreter needed?*

YesNoUnknown
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):*

Experiencing homelessness (adults without dependent children/youth) and have at least one complex health needAt risk for avoidable hospital or emergency department utilizationSerious mental health and/or substance use disorder needsLiving in the community and at risk for long-term care institutionalization due to unmet care needs and social/environmental challengesNursing facility resident transitioning to the community
Adults (21 years and older) Individuals Experiencing Homelessness (without dependent children/youth)

Experiencing homelessness ANDHave 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, OR3+ 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, ANDExperiencing at least one complex social factor influencing health, ANDMeet one or more:High risk for institutionalization, overdose, or suicideUse crisis, ED, urgent care, or inpatient services as primary source of care2+ ED visits or 2+ hospitalizations in past 12 months due to MH/SUDPregnant 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, ANDActively experiencing at least one complex social or environmental factor, ANDAble 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, ANDLikely to transition successfully, ANDAble to reside continuously in the community.
Children & Youth (under 21 years):*

Experiencing homelessness (homeless families or unaccompanied children/youth)At risk for avoidable hospital or emergency department utilizationSerious mental health and/or substance use disorder needsEnrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS conditionInvolved in child welfare
Children & Youth (under 21 years) Individuals Experiencing Homelessness (homeless families or unaccompanied children/youth)

Experiencing homelessness, ORSharing housing due to loss of housing, economic hardship, or similar reason, ORLiving in motels, hotels, trailer parks, or camping grounds due to lack of adequate alternatives, ORLiving in emergency or transitional shelters, ORAbandoned 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, OR2+ 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 MHPsDMC-ODSDMC 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, ANDExperiencing 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 CAUnder 21 and previously in foster care in CA or another state within the past 12 monthsAged out of foster care up to age 26 in CA or another stateUnder 18 and eligible for/in CA Adoption Assistance ProgramUnder 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)
Staff Use Only
1st outreach attempt:

MonthDayYear
Date
2nd outreach attempt:

MonthDayYear
Date
3rd outreach attempt:

MonthDayYear
Date
Date staff made contact with Member

MonthDayYear
Date
Outcome of call
Member was informed that MCP will determine eligibility

YesNo
CPR was forwarded to FCHN

MonthDayYear
Date
Should be Empty:

Bridge to Care - Enhanced Care Management (ECM) Program

Person Being Referred

Insurance/Payor Information

IF THE INDIVIDUAL IS NOT A SAN DIEGO COUNTY RESIDENT AND A MEDI-CAL BENEFICIARY, STOP. THIS INDIVIDUAL IS NOT ELIGIBLE TO PARTICPATE IN FUNDAMENTAL HEALTH’S BRIDGE TO CARE PROGRAM.

Area(s) of Concern

Health Information

Staff Use Only