Submit a Referral DONATE NOW

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:

  1. Outreach & Engagement
  2. Comprehensive Assessment & Care Planning
  3. Enhanced Coordination of Care
  4. Health Promotion
  5. Comprehensive Transitional Care
  6. Member & Family Supports
  7. 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:

  1. Blue Shield Promise Health Plan
  2. Molina Healthcare
  3. Kaiser Permanente

Eligibility Criteria:

To qualify for ECM services through Bridge to Care, individuals must:

  1. Be a San Diego County resident
  2. Be enrolled in a Medi-Cal MCP
  3. 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:

  1. Individuals experiencing homelessness (adults without dependent children/youth)
  2. Individuals at risk for avoidable hospital or emergency department utilization
  3. Individuals with serious mental health and/or substance use disorder needs
  4. Adults living in the community and at risk for long-term care institutionalization due to unmet care needs and social/environmental challenges
  5. Adult nursing facility residents transitioning to the community

Children & Youth (under 21 years) who meet one or more of the following conditions:

  1. Individuals experiencing homelessness (homeless families or unaccompanied children/youth)
  2. Individuals at risk for avoidable hospital or emergency department utilization
  3. Individuals with serious mental health and/or substance use disorder needs
  4. Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS condition
  5. 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

SUBMIT A REFFERAL

Contact Us

Program phone number: (619) 327-9145
Program email address: debon@fundamental.health