What is Bridge to Care?
Bridge to Care is FundaMental Health’s Enhanced Care Management (ECM) program,
delivered in partnership with Full Circle Health Network (FCHN).
We provide whole-person, trauma-informed care coordination for Medi-Cal members with complex
medical, behavioral, and social needs.
Our interdisciplinary team supports members through in-person and telehealth services,
ensuring care is accessible, culturally responsive, and centered on each individual’s goals.
What We Do
Bridge to Care offers seven core ECM services:
- Outreach & Engagement
- Comprehensive Assessment & Care Planning
- Enhanced Coordination of Care
- Health Promotion
- Comprehensive Transitional Care
- Member & Family Supports
- Referral to Community & Social Services
We coordinate across physical health, behavioral health, oral health, housing, and social supports to improve outcomes and reduce avoidable hospitalizations.
Who We Serve
Medi-Cal Managed Care Plans (MCP) Accepted:
- Blue Shield Promise Health Plan
- Molina Healthcare
- Kaiser Permanente
Eligibility Criteria:
To qualify for ECM services through Bridge to Care, individuals must:
- Be a San Diego County resident
- Be enrolled in a Medi-Cal MCP
- Meet criteria for one or more of the Populations of Focus listed below (broad conditions with additional criteria for eligibility)
Populations of Focus:
Adults (21 years and older) who meet one or more of the following conditions:
- Individuals experiencing homelessness (adults without dependent children/youth)
- Individuals at risk for avoidable hospital or emergency department utilization
- Individuals with serious mental health and/or substance use disorder needs
- Adults living in the community and at risk for long-term care institutionalization due to unmet care needs and social/environmental challenges
- Adult nursing facility residents transitioning to the community
Children & Youth (under 21 years) who meet one or more of the following conditions:
- Individuals experiencing homelessness (homeless families or unaccompanied children/youth)
- Individuals at risk for avoidable hospital or emergency department utilization
- Individuals with serious mental health and/or substance use disorder needs
- Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS condition
- Children and youth involved in child welfare
*These categories represent the broad conditions that qualify someone for ECM. Additional criteria within each category determine eligibility.
How to Submit a Referral
Referring to Bridge to Care is simple and secure. We accept self-referrals, as well as referrals from family or other representatives, providers, and community partners. To submit an electronic referral, please click the “Submit a Referral” button below
Contact Us
Program phone number: (619) 327-9145
Program email address: debon@fundamental.health
Support FAQ
Bridge to Care is FundaMental Health’s care management and coordination program for individuals with complex health and life needs. The program provides hands‑on support to help people navigate mental health care, physical health care, and social services, especially during times of instability or crisis.
Bridge to Care is designed to walk alongside individuals who may be interacting with multiple systems and need consistent, relationship‑based support to move toward stability.
Bridge to Care is part of Medi-Cal’s Enhanced Care Management (ECM) benefit.
Enhanced Care Management (ECM) is a Medi‑Cal benefit for individuals with complex health and life needs. ECM provides extra support to help people coordinate care across medical, mental health, and social service systems.
Bridge to Care is FundaMental Health’s ECM program. Through Bridge to Care, individuals receive relationship‑based care management to help reduce barriers, improve stability, and stay connected to the services they need.
ECM does not replace medical care or therapy. Instead, it helps ensure care is organized, accessible, and responsive to the whole person.
Bridge to Care serves children, youth, and adults who are enrolled in Medi-Cal through a participating health plan and meet specific eligibility criteria related to health complexity and life circumstances. Eligibility is based on defined Populations of Focus, which include individuals who may be experiencing:
- Homelessness or housing instability
- Serious mental health and/or substance use challenges
- Frequent hospital or emergency department use
- Risk of long‑term institutional care
- Involvement with child welfare or other systems of care
Eligibility is determined through referral and review in coordination with Medi-Cal Managed Care Plans and partners. Not everyone will qualify, but our team works to help connect individuals with appropriate alternatives when Bridge to Care is not the right fit.
While both programs focus on improving access to mental health support, they serve different needs:
- Foundation of Care provides time‑limited, financially supported therapy for individuals facing barriers to care.
- Bridge to Care provides ongoing care coordination and navigation, helping individuals manage complex medical, mental health, and social needs over time.
Bridge to Care does not replace therapy or medical treatment. Instead, it helps ensure those services are connected, coordinated, and accessible.
Bridge to Care offers comprehensive, person‑centered care management, which may include:
- Care coordination across mental health, physical health, and specialty providers
- Support navigating insurance, appointments, and treatment plans
- Connection to community resources such as housing, food, transportation, and benefits
- Support during transitions (hospital discharge, housing changes, system involvement)
- Ongoing relationship‑based engagement in the community or via telehealth
Services are delivered in ways that meet people where they are physically, emotionally, and culturally.
No. Bridge to Care services are provided as a Medi‑Cal benefit for eligible individuals. There is no cost to participants who are enrolled and approved for the program.
Our team can help answer questions about eligibility, enrollment, and what services are covered.
The Bridge to Care process is designed to be high‑touch, flexible, and relationship‑driven.
Here’s what the process typically looks like:
- Referral and eligibility review
Referrals may come from providers, community partners, family members, or individuals themselves. Eligibility is reviewed based on established criteria. - Engagement and relationship building
Once enrolled, individuals are connected with a care manager who takes time to understand their goals, needs, and priorities. - Care coordination and ongoing support
The care team works alongside the individual to coordinate services, reduce barriers, and support progress over time. - Transitions toward stability
As needs change, Bridge to Care helps individuals move toward more stable, sustainable supports while maintaining continuity.
Bridge to Care does not replace therapy or medical treatment. Instead, it helps individuals access, coordinate, and stay connected to appropriate mental health providers, medical providers, and support services.
When individuals need therapy, psychiatry, or substance use treatment, the Bridge to Care team supports referrals, coordination, and follow‑through.
Bridge to Care is not time‑limited. Enrollment length depends on individual needs, eligibility, and program guidelines.
The focus is on providing support for as long as it is clinically appropriate and beneficial, while helping individuals move toward long‑term stability and connected care.
Bridge to Care is built around relationship‑based care, meeting people where they are and helping them navigate systems that can feel overwhelming or fragmented.
The program emphasizes:
- Consistent, trusted care relationships
- Coordination across systems (not silos)
- Trauma‑informed, community‑based support
- A focus on stability, dignity, and long‑term wellbeing
Bridge to Care exists to ensure that no one has to navigate complex health and social systems alone.
Don’t see your question here? Email us: hello@fundamental.health