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Enhanced Care Management & Community Supports Housing Navigation Referral Form

To submit a referral for Enhanced Care Management (ECM) and/or Community Supports (CS) Housing Navigation to Neighborhood Networks, please complete all required fields below. Before submitting a referral, please ensure the member is aware of the referral, has agreed to be referred, and understands that they will be contacted by Neighborhood Networks.

All referrals are reviewed for eligibility within 72 hours of receipt. Once eligibility has been confirmed, members will be contacted within 5–10 business days.

Please note:

  • Submit one referral form per individual.
  • ECM and CS services are not intended for urgent or emergency needs.
  • ECM and CS Housing Navigation are complementary, non-duplicative services. Members may be referred for both services simultaneously when appropriate.
  • Include detailed referral notes describing the member's needs, current circumstances, barriers, and any other relevant information that will help ensure appropriate service coordination.

CS HTNS Eligibility (Page 27): DHCS Community Supports Policy Guide: Volume 2
ECM Eligibility (Page 10): CalAIM Enhanced Care Management Policy Guide
ECM POF & HTNS Screening

POF & Eligibility Screening

Some programs are designed for communities with documented maternal health disparities.

Housing




High Utilizer






Justice-Involved


Nursing Facility


Health Conditions



Behavioral Health Conditions




Foster Care








Please include anyone else who would like to receive updates regarding this referral.









MM/DD/YYYY




Which method of contact is best to use to reach the member?
















Check for member's MRN in corresponding managed care plan portal if possible.

If member is with CHG and is requesting CS services we will need caregiver's full name and CIN to find their housing domain.


MM/DD/YYYY



Consent into Program Services
ECM Services
What is ECM? ECM is a free Medi-Cal benefit for members who have complex health or life needs. If you enroll, we’ll pair you with someone called a lead care manager. That person works with you and your other providers to coordinate your medical care, your behavioral health care, and social needs like housing, food, and transportation — all under one service. ECM doesn’t replace your doctor or therapist; we work alongside them. What your ECM Team will do:

  • Meet with you in person or by phone — wherever works best for you.
  • Build a Care Plan with you that reflects your needs and goals.
  • Coordinate with your doctors, specialists, and behavioral health providers.
  • Connect you to community resources like housing, food, transportation, and other supports
Your Rights
  • Participation is voluntary. You can stop participating at any time.
  • Choosing not to enroll, or choosing to stop, will not affect your Medi-Cal or your other benefits.
  • These services are free. Materials and an interpreter in your preferred language are also free.
  • You can request a different lead care manager or a different ECM provider at any time.
  • You can file a complaint or grievance directly with us or with your Medi-Cal plan at any time.


Housing Transition Navigation Services

What is Housing Transition Navigation Services?

Housing Transition Navigation Services (HTNS) is a free Medi-Cal benefit for members who need help finding and securing stable housing. If you enroll, we'll pair you with someone called a housing navigator. That person works with you to identify your housing needs, search for housing options, and complete the steps needed to move in — all under one service. HTNS doesn't replace your other care providers; we work alongside them.


What your Housing Navigator will do:

  • Meet with you in person or by phone — wherever works best for you.
  • Build a Housing Plan with you that reflects your needs, preferences, and goals.
  • Help you search for and apply to housing, including connecting you with landlords or housing programs.
  • Assist with move-in needs, such as security deposits, application fees, and move-in essentials, where eligible.
  • Connect you to other community resources and supports as needed.

Your Rights

  • Participation is voluntary. You can stop participating at any time.
  • Choosing not to enroll, or choosing to stop, will not affect your Medi-Cal or your other benefits.
  • These services are free. Materials and an interpreter in your preferred language are also free.
  • You can request a different housing navigator or a different HTNS provider at any time.
  • You can file a complaint or grievance directly with us or with your Medi-Cal plan at any time.


Information about ASCMI - Authorization to Share Confidential Member Information
As part of your enrollment in ECM or Community Supports, the Neighborhood Networks team will be sending you consent forms called ASCMI through email and will ask for your e-signature.

Link to more information:  Authorization to Share Confidential Member Information | DHCS
What is the ASCMI Form?
The ASCMI Form is a document requesting your permission to allow your Care Partners  to share your information with each other. This can help you avoid having to share the same information multiple times or sign a new consent form each time your Care Partners need to share your information. It can also make referrals and appointments for your ongoing care needs with other providers faster and easier.

Why am I being asked to sign the Form?
Signing the Form will help your Care Partners to better recommend services and supports to help meet your health care or other needs. They will also be able to refer you to these services and help to coordinate them.
For example, if you need support with finding housing, and you have signed the ASCMI Form, your doctor can share more information about you with a housing provider. This can help the housing provider find the housing that is best for you and your needs.


Enhanced Care Management Population of Focus *
Please select all that apply.
ECM Referral Notes
Please include current health needs here and any additional information related to member's Population of Focus.

ECM Eligibility (Page 10):  CalAIM Enhanced Care Management Policy Guide

Enrollment in other programs and services*
Indicate other programs and services that the member is receiving under Medi-Cal. Some Medi-Cal services may require coordination with other services. Members may be excluded from receiving ECM and these similar services at the same time.
Housing Transition Navigation Services Eligibility
Members must meet at least one other PoF outside of risk of homelessness/homelessness to qualify for CS HTNS services. Please select all that apply.
CS Referral Notes
Describe the member’s current housing situation in detail, including where they are sleeping. If they are in a shelter, state whether it is an emergency shelter (day-to-day) or a transitional program. For transitional programs, include the exit date. Members qualify as ‘at risk’ of homelessness only if their exit date is within 30 days.

Requests that do not specify members current housing situation will be returned for additional information. Please include any additional information related to member's Population of Focus.

Visit the DHCS CS HTNS Eligibility (Page 27) for current criteria: 
DHCS Community Supports Policy Guide: Volume 2


A Note About Neighborhood Networks' Use of AI

To help us listen carefully and keep accurate records, we use artificial intelligence (AI) tools during our phone calls to transcribe and summarize our conversations. These AI-generated transcripts and summaries are saved in the member's record. Neighborhood Networks uses them to document calls and prepare for the member's next visit. AI is a tool to help our staff — not a replacement for them. Decisions about the member's care are made by people, not by AI. The member's information is protected the same way all the member's health information is protected, under HIPAA and California privacy laws. If the member has any questions or concerns about how Neighborhood Networks uses AI, the memebr should let their care team know.

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