Enhanced Care Management Eligibility

1. Are experiencing homelessness, defined as meeting one or more of the following conditions:
   (i) Lacking a fixed, regular, and adequate nighttime residence; 
   (ii) Having a primary residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground; 
   (iii) Living in a supervised publicly or privately operated shelter, designed to provide temporary living arrangements (including hotels and motels paid for by federal, state, or local government programs for low-income individuals or by charitable organizations, congregate shelters, and transitional housing); 
   (iv) Exiting an institution into homelessness (regardless of length of stay in the institution); 
   (v) Will imminently lose housing in next 30 days; 
   (vi) Fleeing domestic violence, dating violence, sexual assault, stalking, and other dangerous, traumatic, or life-threatening conditions relating to such violence; AND
    
2. Have at least one complex physical, behavioral, or developmental need, with inability to successfully self-manage, for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high- cost services.

Children, Youth, and Families with members under 21 years of age who:

1. Are experiencing homelessness, as defined above in (a) under the modified HHS 42 CFR Section 11302 “Homeless” definition; OR
2. Sharing the housing of other persons (i.e., couch surfing) due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; or abandoned in hospitals (in hospital without a safe place to be discharged to), as modified from the 45 CFR 11434a McKinney-Vento Homeless Assistance Act definition of “at risk of homelessness

Adults who meet one or more of the following conditions:

1. Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence;
2. 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.
3. OR is at risk for avoidable hospital or emergency room (ED) utilization and who would benefit from ECM but who may not meet the numerical threshold specified above. 
   
   Children and youth who meet one or more of the following conditions:

1. Three or more ED visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence

2. 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.

3. OR is at risk for avoidable hospital or emergency room (ED) utilization and who would benefit from ECM but who may not meet the numerical threshold specified above.

Adults who:

1. Meet the eligibility criteria for participation in, or obtaining services through: (i) SMHS delivered by MHPs; (ii) The Drug Medi-Cal Organization Delivery System (DMC-ODS) OR the Drug Medi- Cal (DMC) program;15 AND
2. Are experiencing at least one complex social factor influencing their health (e.g., lack of access to food, lack of access to stable housing, inability to work or engage in the community, high measure (four or more) of ACEs based on screening, former foster youth, history of recent contacts with law enforcement related to mental health and/or substance use symptoms; AND

3. Meet one or more of the following criteria: (i) Are at high risk for institutionalization,16 overdose, and/or suicide; (ii) Use crisis services, EDs, urgent care, or inpatient stays as the primary17 source of care; (iii) experienced two or more ED visits or two or more hospitalizations due to serious mental health or SUD in the past 12 months; 
   
   Children and youth who:

   1. Meet the eligibility criteria for participation in, or obtaining services through one or more of:
   (i) SMHS delivered by MHPs; 
   (ii) The DMC-ODS OR the DMC program. 
   No further criteria are required to be met for children and youth to qualify for this ECM Population of Focus.

Adults who:

1. 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
2. Have at least one of the following conditions (See Appendix C for definitions):
   (i) Mental illness; 
   (ii) SUD; 
   (iii) Chronic Condition/Significant Non-Chronic Clinical Condition; 
   (iv) Intellectual or Developmental Disability (I/DD); 
   (v) Traumatic Brain Injury (TBI); 
   (vi) HIV/AIDS; 
   (vii) Pregnant or Postpartum 
   
   Children and youth under 21 or former foster youth between 18 and 26 who are transitioning from a youth correctional facility or adult jail/prison or transitioned from being in a youth correctional facility or adult jail/prison within the past 12 months. No further criteria are required to be met for Children and Youth to qualify for this ECM Population of Focus.

Adults who:

1. Are living in the community who meet the SNF Level of Care (LOC) criteria;19 OR who require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illness or injury;20 AND
2. Are actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with activities of daily living (ADLs), communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision- making, poor or inadequate caregiving which may appear as a lack of safety monitoring);21 AND
3. Are able to reside continuously in the community with wraparound supports (i.e., some individuals may not be eligible because they have high-acuity needs or conditions that are not suitable for home-based care due to safety or other concerns).

Adult nursing facility residents who:

1. Are interested in moving out of the institution; AND
2. Are likely candidates to do so successfully; AND
3. Are able to reside continuously in the community.

Children and youth who:

1. Are enrolled in CCS OR CCS WCM; AND
2. Are experiencing at least one complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of ACEs screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health and/or substance use symptoms.

Children and youth who meet one or more of the following conditions:

1. Are under age 21 and are currently receiving foster care in California; Are under age 21 and previously received foster care in California or another state within the last 12 months; 
   1. 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;
   2. Are under age 18 and are eligible for and/or in California’s Adoption Assistance Program;
   3. Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months.

Adults and youth who:

1. Are pregnant OR are postpartum (through 12 months period); 
   AND
2. Are subject to racial and ethnic disparities as defined by California public health data on maternal morbidity and mortality.