ECM support for patients transitioning from skilled nursing facilities.
We partner with SNF discharge planners and social workers to support Medi-Cal patients transitioning safely back to the community through Enhanced Care Management (ECM) and Community Health Worker (CHW) services. Our team provides ongoing coordination and support to help reduce avoidable hospital readmissions and ensure patients successfully stabilize after discharge.
Who to refer — and what we do
A quick reference for discharge planning. If a patient fits these criteria, we can help.
Who to refer
- Medi-Cal members
- Patients discharging from a SNF
- Multiple chronic conditions or complex needs
- High risk for hospital readmission
- Needs housing, transportation, or access to care
- Needs care coordination and community support
What we provide
- Care coordination across providers
- Community Health Worker (CHW) support
- Assistance with follow-up appointments
- Connection to housing, food, and transportation
- Address social determinants of health
- Ongoing support to stabilize patients
Why partner with us
Five concrete outcomes you can hand off to our team.
Reduce gaps in care after discharge.
Support high-risk patients beyond the SNF.
Improve continuity of care.
Address medical and social needs together.
Reduce avoidable ED visits and readmissions.
Submit a referral.
Complete the form — our team will review and follow up promptly. Most referrals are acknowledged within one business day.
Need to reach our team directly?
For urgent referrals or questions about eligibility, our intake line is monitored during business hours. We serve Medi-Cal members across Northern California and Orange County.