Enhanced Care Management (ECM) Provider Information

Homelessness (Adult)

• Are experiencing homelessness and
• Have at least one complex physical, behavioral or developmental need, with inability to successfully self-manage.

Homelessness (Pediatric)

Are experiencing homelessness or are:

• Sharing the housing of other persons (i.e., couch surfing), or
• Living in motels, hotels, trailer parks or camping grounds, or
• Living in emergency or transitional shelters or
• Are abandoned in hospitals(in hospital without a safe place to be discharged to).

At Risk of Avoidable ED/Hospital Use (Adults)

• Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence or
• Three or more unplanned hospital and/or short-term skilled nursing facility (SNF) stays in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

At Risk of Avoidable ED/Hospital Use (Pediatric)

• Three or more ED visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence or
• Two or more unplanned hospital and/or short-term SNF stays in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

SMI/SUD (Adults)

Meet the eligibility criteria for participation in or obtaining services through:

• SMHS delivered by MHPs, and
• The Drug Medi-Cal Organization Delivery System (DMC-ODS) or the Drug Medi-Cal (DMC) program, and
• Are experiencing at least one complex social factor influencing their health and
• Meet one or more of the following criteria:
  • Are at high risk for institutionalization, overdose and/or suicide.
  • Use crisis services, EDs, urgent care or inpatient stays as the primary source of care.
  • Experienced two or more ED visits or two or more hospitalizations due to serious mental health or SUD in the past 12 months.
  • Are pregnant or postpartum (12 months from delivery).

SMI/SUD (Peds)

Meet the eligibility criteria for participation in, or obtaining services through one or more of:

• SMHS delivered by MHPs.
• The DMC-ODS or the DMC program.

• Adults living in the community who meet the SNF Level of Care (LOC) criteria or who require lower-acuity skilled nursing, and
• Are actively experiencing at least one complex social or environmental factor influencing their health and
• Are able to reside continuously in the community with wraparound supports.

Adult nursing facility residents who:

• Are interested in moving out of the institution, and
• Are likely candidates to do so successfully and
• Are able to reside continuously in the community.

• Are enrolled in CCS or CCS WCM, and
• Are experiencing at least one complex social factor influencing their health.

Children who:

• Are under age 21 and are currently receiving foster care in California or
• Are under age 21 and previously received foster care in California or another state within the last 12 months or
• Have aged out of foster care up to age 26 (having been in foster care on their 18th birthday or later) in California or another state or
• Are under age 18 and are eligible for and/or in California’s Adoption Assistance Program or
• Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months.

• Have a diagnosed I/DD and
• Qualify for eligibility in any other ECM Population of Focus.

• Are pregnant or are postpartum (through 12 months period) and
• Meet one or more of the following conditions:
  • Qualify for eligibility in any other adult or youth ECM Population of Focus.

Adults who:

• Are transitioning from a correctional facility (e.g., prison, jail or youth correctional facility) or transitioned from correctional facility within the past 12 months; and

• Have at least one of the following conditions:
  • Mental illness.
  • SUD.
  • Chronic Condition/Significant Non-Chronic Clinical Condition.
  • Intellectual or Developmental Disability (I/DD).
  • Traumatic Brain Injury (TBI).
  • HIV/AIDS.
  • Pregnant or Postpartum.

• Children and youth who are transitioning from a youth correctional facility or transitioned from being in a youth correctional facility within the past 12 months.

Adults and youth who:

• Are pregnant or are postpartum (through 12 months period) and
• Are subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality (the racial and ethnic groups experiencing disparities in care for maternal morbidity and mortality are Black, American Indian and Alaska Native, and Pacific Islander pregnant and postpartum individuals).