A California Nonprofit · CalAIM ECM & Community Supports

Whole-person care where people actually live.

Community Bridge Foundation is a field-based care organization serving high-need Medi-Cal members across Los Angeles, the Inland Empire, San Diego, and Imperial County. We deliver the wraparound support that office visits alone can't provide — at no cost to your patients, and no added work for your practice.

Refer a patient → See what we deliver

4Counties served

2Core programs

5Community Supports services

$0Cost to your patients

01 · Services

Two programs. One coordinated team.

Our work is delivered under California's CalAIM initiative, which expands Medi-Cal beyond the four walls of the clinic. Both programs are fully covered as Medi-Cal benefits — there is no charge to your patients.

Program 01

Enhanced Care Management (ECM)

A whole-person, in-the-community benefit for high-need Medi-Cal members. Our lead care managers coordinate medical, behavioral, dental, developmental, and social services — so patients get the wraparound support that office visits alone can't provide.

Populations of focus

Individuals experiencing homelessness
High utilizers of avoidable ED & inpatient care
Adults & youth with serious mental illness or SUD
Nursing facility residents transitioning to the community

Program 02

Community Supports (CS)

Medically appropriate, cost-effective alternatives to traditional services — covered by the member's Medi-Cal Managed Care Plan. We deliver the social interventions that drive the clinical outcomes you're working toward.

Services we provide

Housing Transition & Navigation Services
Housing Deposits & Tenancy Sustaining Services
Recuperative Care (Medical Respite)
Short-Term Post-Hospitalization Housing
Environmental Accessibility Adaptations

02 · Who we serve

The patients your team already knows by name.

The frequent flyers. The lost-to-follow-up. The ones who show up in the ED every six weeks because nothing in the discharge plan addresses why they came in. We work with them — in their world, on their timeline.

People experiencing homelessness

Outreach in encampments, shelters, and transitional sites — paired with housing navigation and benefits enrollment.

ii.

High utilizers of avoidable acute care

Members with repeated ED visits or inpatient stays where the underlying drivers are social, behavioral, or systemic.

iii.

Adults and youth with SMI or SUD

Coordinated care across primary, behavioral, and substance use treatment — with closed-loop reporting back to your team.

iv.

Members transitioning from nursing facilities

Discharge planning, home modifications, and tenancy support so the move to the community is sustainable.

03 · Why refer to us

Built to remove friction — not add it.

We designed Community Bridge Foundation around what hospital discharge planners, clinic care teams, and community partners actually told us they needed. It comes down to six things.

No cost to your patients

Fully covered as a Medi-Cal benefit. No copays, no out-of-pocket, no surprise bills.

ii.

No added work for your practice

We handle outreach, engagement, and care coordination. You send the referral; we do the legwork.

iii.

Closed-loop communication

You receive engagement updates and care plan summaries — not silence after the handoff.

iv.

Field-based teams

We meet members in homes, shelters, hospitals, and the community — wherever the work needs to happen.

Culturally responsive care

Multilingual staff (English, Spanish, and more). Trauma-informed, harm-reduction oriented.

vi.

Same-day warm handoffs

Hospitals, clinics, and community partners can hand off in real time — not at the next intake cycle.

04 · Board of Directors

Stewards of the mission.

Our Board of Directors brings together leaders from medicine, social services, and community organizing — chosen for their direct experience with the populations we serve and their commitment to whole-person care.

Founder · Board Chair

Name forthcoming

Founder of Community Bridge Foundation. Leads strategy, credentialing, and Managed Care Plan contracting.

Co-Founder · Operations

Name forthcoming

Co-founder leading operations, technology, and clinical workflows — including HIPAA compliance, EHR selection, and care management infrastructure.

Director

Name forthcoming

Board member supporting MCP outreach, contracting strategy, and partner development across our service counties.

Medical Director

Name forthcoming

Provides clinical oversight and physician leadership across our care coordination programs in Imperial, San Diego, and the Inland Empire.

Open Seat

Community Representative

We are actively seeking a board member with lived experience of homelessness, housing instability, or behavioral health recovery. Get in touch.

Open Seat

Treasurer / Finance

Recruiting a board member with nonprofit financial leadership and audit experience to chair the Finance Committee. Get in touch.

05 · Community Events

Show up where care happens.

Our work doesn't stop at referrals. We host and partner on community events across our service area — outreach clinics, resource fairs, and partner convenings. Open to clinicians, community members, and partner organizations.

TBD · Calendar forthcoming

Our community events calendar is taking shape. Outreach clinics, resource fairs, provider workshops, and partner convenings across our service area — announcements coming soon.

Email to be notified →

06 · Donate

Fund the work between the visits.

Medi-Cal covers our care management and community supports services. It does not cover the bus pass that gets someone to a job interview, the cell phone that keeps a member in contact with their care team, or the security deposit gap that makes the difference between a lease and another month on the street. That's where your support comes in.

Where your gift goes

Every dollar funds direct member assistance — the small, immediate needs that unlock everything else in a person's care plan. We track every gift against outcomes and report back annually.

$25
covers a 30-day transit pass for a member commuting to medical and behavioral health appointments.
$75
provides a basic prepaid phone with three months of service — keeping a member connected to their care team.
$250
funds an emergency hygiene & clothing kit at intake for a member moving from encampment to recuperative care.
$500
closes a security deposit gap when housing vouchers don't cover the full move-in cost.
$1,000
underwrites a full month of community outreach for one care manager — the field hours that drive every other outcome.

07 · Make a referral

Send us the patient. We'll take it from there.

The fastest path is a phone call or a secure email — we'll confirm receipt the same business day and begin outreach within 48 hours of an accepted referral. For Managed Care Plan contracting and partnership inquiries, use the partnerships line below.

Email a referral →

Patient referrals

referrals@communitybridgefoundationca.org

Phone line coming soon — referrals welcome by email today

MCP & partnerships

partnerships@communitybridgefoundationca.org

For Managed Care Plan contracting

Service area

Los Angeles · Inland Empire · San Diego · Imperial County

Field-based, county-wide coverage