Enhanced Care Management and Community Supports Referral Form

Kaiser Permanente accepts referrals for KP Medi‐Cal members that are presumed eligible for Enhanced Care Management (ECM) and/or Community Supports (CS) services. If a member is eligible, KP will issue an authorization to a supplier in our network of contracted vendors to provide the service.

Enhanced Care Management is available in all KP’s service areas. The benefit is limited to specific Populations of Focus defined by the Department of Health Care Services and provides intensive care management to members with complex health and/or social needs.

Community Supports are non-medical services provided as cost-effective alternatives (e.g., housing navigation, asthma remediation) to traditional medical services and settings. Community Supports availability varies by county.

For Northern California referrals, submit the completed form to REGMCDURNs‐KPNC@kp.org via secure email. For Southern California referrals, submit the completed form to RegCareCoordCaseMgmt@kp.org via secure email. Note: Referrals from KP staff should be submitted via KP HealthConnect.

Enhanced Care Management and Community Supports Referral Form

Kaiser Permanente accepts referrals for KP Medi‐Cal members that are presumed eligible for Enhanced Care Management (ECM) and/or Community Supports (CS) services. If a member is eligible, KP will issue an authorization to a supplier in our network of contracted vendors to provide the service.

Enhanced Care Management is available in all KP’s service areas. The benefit is limited to specific Populations of Focus defined by the Department of Health Care Services and provides intensive care management to members with complex health and/or social needs.

Community Supports are non-medical services provided as cost-effective alternatives (e.g., housing navigation, asthma remediation) to traditional medical services and settings. Community Supports availability varies by county.

For Northern California referrals, submit the completed form to REGMCDURNs‐KPNC@kp.org via secure email.

For Southern California referrals, submit the completed form to RegCareCoordCaseMgmt@kp.org via secure email.
Note: Referrals from KP staff should be submitted via KP HealthConnect.

Fields marked with an asterisk (*) are mandatory.

Referrer Name

Referrer Organization

Referrer Email Address

Referrer Phone Number

Referrer Fax Number

If other, please list below

Is the member aware you are submitting a referral on their behalf?

Yes

Unknown

Has the member consented to participating in the program/programs they are being referred to?

Yes

Unknown

Membership Information

Is the person being referred a Medi-Cal Managed Care member with Kaiser Permanente? If the member IS NOT a Medi-Cal Managed Care member, they are ineligible for these services at Kaiser Permanente.

Yes

Unknown

If no, the member does not qualify. Other resources may be available to the member through Kaiser Permanente’s Thrive Local platform, which is available to all Kaiser Permanente members.

Full Name

Kaiser MRN (if known)

Medi-Cal CIN # (if known)

Date of Birth

Preferred Language

Phone Number

Preferred call time

California county of residence

Address

No permanent address

No permanent address at this time

Mailing Address

Same as Address

No Mailing Address

Previous and/or Current Service Usage

Does the member currently receive or have previously received support services from an outside organization?

Yes (if yes, complete next section)

No (If no/unsure, skip to next section)

Organization 1 name

Does the member wish to stay connected with or become reconnect with the above organization (if applicable)?

Yes

Unknown

Organization point of contact

Point of contact email

Point of contact phone number

Applicable notes

Organization 2 name:

Does the member wish to stay connected with or become reconnect with the above organization (if applicable)?

Yes

Unknown

Organization point of contact

Point of contact email

Point of contact phone number

Applicable notes

Services Requested in this Referral

Please check all applicable Enhanced Care Management and Community Support (CS) fields for each referral requested on behalf of the member. After the referral is submitted, the member must be screened for eligibility by a member of Kaiser Permanente’s authorization team before the referral can be approved.

Option 1

Available in ALL counties

Select ALL complex physical, behavioral, and developmental conditions applicable:

If Other, please provide more detail

Developmental Disability

Intellectual/Developmental Disability

Other

If Other, please provide more detail

Option 2

Available in ALL counties

Select ONE program for referral

Housing Transition/Navigation

Housing Tenancy & Sustaining

Select ONE that applies

Individual meets the HUD definition of homelessness

Individual meets the HUD definition of at risk of homelessness

HUD Definition of homelessness

At risk of homelessness

Select ALL that apply:

Individual is fleeing or attempting to flee domestic violence

Individual is living with children

Individual is currently receiving housing navigation from an organization (Please provide the Organization name below)

Individual has previously received financial support for a housing deposit

Individual is currently matched to a housing voucher or subsidy

Individual has an immediate safety concern

Organization's name

Enrollment date

Option 3

Only Available in SOME counties (Please check this list for more info)

Select one that applies

Individual meets the HUD definition of homelessness

Individual is at risk of homelessness

HUD Definition of homelessness

At risk of homelessness

Individual is exiting a facility, such as an inpatient hospital, residential substance use disorder treatment facility, residential mental health treatment facility, recuperative care, nursing facility or correctional facility.

Organization's Name

Organization Type

Expected discharge date

Option 4

Only Available in SOME counties (Please check this list for more info)

Select ALL that apply

Individual is experiencing homelessness

Individual left homelessness and obtained housing in the last 24 months

Individual is at risk of hospitalization or institutionalization

Individual would benefit from acquiring, retaining, and improving self-help, socialization, and adaptive skills (e.g. developing personal relationships, taking public transportation, money management) necessary to live successfully in their environment.

If Other, please provide more detail

Option 5

Documentation WILL be requested for the medical need for this service.

Only Available in SOME counties (Please check this list for more info)

Select ALL qualifying criteria

Individual is homeless OR at risk of homelessness

Individual is at risk of hospitalization

Individual has a medical need that will be aided by recuperative care

Individual is scheduled to exit hospitalization

Hospital name and discharge date

HUD Definition of homelessness

At risk of homelessness

Option 6

Only Available in SOME counties (Please check this list for more info)

Select ALL that apply

Individual currently receives caregiving services (paid)

Individual currently receives caregiving services (unpaid)

Individual has a residential address

Option 7

Only Available in SOME counties (Please check this list for more info)

Select ALL qualifying criteria:

Individual is currently residing within a nursing facility

Individual has been residing within a nursing facility for 60+ days

Facility Name and Facility Type

Select ONE that applies

Individual is interested in relocating to an assisted living facility

Individual is interested in relocating to a private residence

Option 8

Only Available in SOME counties (Please check this list for more info)

To qualify, ALL eligibility criteria must be met

Individual is interested in remaining in the community

Individual is willing and able to reside safely in an assisted living facility

Individual is currently receiving medically necessary nursing facility level of care (LOC) or meet the minimum criteria to receive nursing facility LOC services and in lieu of going into a facility, is choosing to remain in the community and continue to receive medically necessary nursing facility LOC services at an Assisted Living Facility

Option 9

Only Available in SOME counties (Please check this list for more info)

Members MUST apply for In Home Supportive Services (IHSS) before receiving this community support. If the member needs assistance applying to IHSS, have one of their Kaiser Permanente care team providers submit an appropriate support service request.

Has the member applied for IHSS?

Yes

Currently has IHSS and needs additional support

Referral date, if known

IHSS hours currently receiving, if applicable

Select ALL qualifying criteria

Individual is at risk of hospitalization or institutionalization

Individual has applied for IHSS services

*If no, member is not eligible for Personal Care and Homemaker Service through Kaiser Permanente

Option 10

Documentation WILL be requested for the medical need for this service.

Only Available in SOME counties (Please check this list for more info)

Select ONE that applies

Individual is at risk of hospitalization or institutionalization at a facility

Individual is currently hospitalized or institutionalized and seeking to reenter the community

Home modification requested

Option 11

Documentation WILL be requested for the medical need for this service.

Only Available in SOME counties (Please check this list for more info)

Select ALL qualifying criteria

Individual has poorly controlled asthma

Individual has received care for their asthma by a health care provider

If other, please list intervention

Option 12

Qualifying conditions may include cancer, cardiovascular disorders, chronic lung disorders, chronic or disabling mental/behavioral disorders, congestive heart failure, COVID post discharge, diabetes, end stage renal disease, gestational Diabetes, high risk perinatal conditions, HIV, pulmonary, rehab, and stroke. This support is not meant to respond solely to food insecurity.

Only Available in SOME counties (Please check this list for more info)

Select ALL qualifying criteria

Individual is exiting a facility, such as an inpatient hospital, residential substance use disorder treatment facility, residential mental health treatment facility, nursing facility or correctional facility

Individual has extensive care coordination needs

Individual has a qualifying chronic condition

Organization Name

Organization Type

Expected Discharge Date

Condition(s)

Lifespring Homenutrition

5.0

Based on 10 reviews

review us on

Hannah HK

05:05 30 Apr 24

I cannot enough express my gratitude for your help and the fact that you respected my selective religious food choices, you delivered frozen clean simple disposable boxes of mostly ready to go meals , sealed, sanitary, cold in big insulated bags. Thank you truly !

S Maw

23:51 05 Apr 24

I had a catastrophic event requiring a long hospital stay and at discharge my HMO offered Lifespring meal services. Initially, I was offered a puree diet and then as I improved a regular diet. Staff were kind, patient, and their supervisor, Christina was extremely accommodating. This is an amazing company who goes the extra mile to ensure patients receive their meals promptly. The food is delicious with a variety of meals. I would highly recommend Lifespring.

J Grant

19:39 24 Mar 24

Lora “LaLa” Bender

00:09 08 Apr 23

My food.

M Maithalouni

16:57 23 Mar 23

Balanced meals excellent customer service. Thank you

Carol Worth (CarolNikkie)

23:27 18 Jan 21

I've been receiving Lifespring meals for the past several years. I find them to be fresh, convenient, and delicious! The meals are both balanced and nutritious, and, because they are prepared fresh, and then flash frozen; all one needs is a microwave! Delivery is prompt and courteous, and if ever you want to make a change, the friendly office staff is available by phone. Thank you, Lifespring! 🤗😘

Garth Ship

03:04 04 Dec 20

Christina totally went above and beyond for me with excellent service.Delivered right on time to my door by the friendly driver. The meals are delicious and have definitely lifted my spirits through these troubled times. Thank you Lifespring for great service and the delicious meals you provide.

Leticia nicole Avelino

18:04 17 Mar 20

They have been a blessing to my grandmother for a low sodium diet, got her back on track and portions are perfect!

Samantha Perez

19:36 27 Jun 19

I am very happy with the service provided and options for my elderly family member. Taste and quality earn a 5 star review.

LifeSpring Home Nutrition

Select Language

Membership Information

Previous and/or Current Service Usage

Services Requested in this Referral

Option 1

Option 2

Option 3

Option 4

Option 5

Option 6

Option 7

Option 8

Option 9

Option 10

Option 11

Option 12