Clearwater Care Partners delivers Enhanced Care Management to Medi-Cal members whose medical, behavioral, and social needs cross more systems than any one of them can manage alone. One lead care manager. One accountable team. Across Los Angeles and the Inland Empire.
A member leaves the hospital with a new diagnosis, no stable housing, an untreated substance use disorder, and a plan card they have never used. Four systems, four intake processes, four waitlists, and no one accountable for whether any of it connects.
Enhanced Care Management exists to put one person in charge of that whole picture. That person is a Clearwater lead care manager.
A single named person who owns the member's full picture. Not a call center, not a rotating queue.
We meet members where they are: street, shelter, hospital bedside, clinic, or residential program.
A referral isn't finished when it's sent. It's finished when we confirm the member arrived.
Response times, outreach attempts, and enrollment outcomes are tracked and reportable to the health plan.
Enhanced Care Management is a Medi-Cal benefit under CalAIM designed for members with complex medical, behavioral health, and social needs. Clearwater brings those needs into one coordinated plan through comprehensive assessment, care planning, field-based engagement, health system navigation, and closed-loop follow-through.
The benefit covers eight functions. Clearwater delivers all eight.
A structured look at medical, behavioral, functional, and social needs together, including housing, food, benefits, and transportation.
A written plan built with the member around goals they actually claim, reviewed and revised as circumstances change.
We convene the people already involved, including primary care, specialists, behavioral health, and housing, so the plan is one plan.
Appointments coordinated, transportation arranged, authorization needs followed through, and missed connections actively re-engaged.
The days around a hospital discharge or a move between programs are where members are lost. We are present in that window.
Referrals into housing, food, benefits enrollment, legal aid, and recovery support, with follow-through to confirm the member connected.
Education, coaching, and support for the people around the member, often the difference between a plan that holds and one that does not.
Continuous engagement at a cadence set by acuity, not a single assessment and a closed file.
Four minutes, secure, and acknowledged within one business day.
Refer a MemberClearwater does not serve every ECM population. We are built for the two that are hardest to reach and easiest to lose: people without stable housing, and adults living with serious mental illness or substance use disorder, very often both at once. Depth in those two populations is the entire strategy.
Members who are unsheltered, in shelter or interim housing, or at imminent risk of losing housing, including those cycling between the street, the emergency department, and short stays.
Adults with significant behavioral health needs, substance use disorder, or both, frequently alongside chronic physical conditions and repeated acute care use.
Eligibility is determined by the member's Medi-Cal managed care plan, not by us. If you think a member needs this and you are not certain they are eligible, send the referral anyway. We verify enrollment, plan, and population of focus, and we tell you either way.
Refer a MemberYou are already doing the work of holding a member's care together. Referring to ECM moves that weight to a team whose entire job is to carry it, and who reports back to you.
A discharge destination for members who keep returning. We take the referral before discharge and make contact in the transition window.
We extend the care team beyond the clinical visit, addressing the social, logistical, and coordination needs that can otherwise interfere with the treatment plan.
Continuity when a client steps down from treatment. We cover the physical health and housing side while you hold the clinical work.
Health system navigation for the people already in your programs, without adding to your staff's caseload.
An ECM provider specialized in the populations hardest to engage, with response times and enrollment outcomes tracked and reportable. See our health plan page ›
Submitted securely and logged with a referral ID. Acknowledged within one business day.
Medi-Cal enrollment, managed care plan, and population of focus verified.
We reach the member where they are, in the field, not by voicemail alone.
Comprehensive review of medical, behavioral, and social needs together.
A lead care manager is assigned and the plan is built with the member.
Continuous engagement, with updates back to the referring partner.
Clearwater Care Partners is a California company delivering Enhanced Care Management across Los Angeles, San Bernardino, and Riverside counties. Clearwater was built to close the gaps between medical care, behavioral health, housing, social services, and community-based support. We specialize in members whose needs cross multiple systems, and we build the field-based coordination required to keep those systems connected.
Our work sits in the space between those systems, where a discharge summary does not reach a shelter, where a shelter bed and a clinic appointment fall on opposite sides of the county, where a member has a plan card and no way to use it. The members hardest to reach are not unreachable. They are under-resourced by systems that were never designed to coordinate with each other.
We serve a defined set of populations of focus exceptionally well rather than spreading thin across all of them. Depth in the hardest populations is the point.
Our field-based model prioritizes teams with experience engaging populations facing homelessness, behavioral health needs, substance use challenges, and other barriers to traditional care.
A referral is not complete when it is sent. Our documentation standard is confirmation that the member arrived, and an update back to whoever referred them.
Response time, outreach attempts, and enrollment outcomes are tracked as the work happens, so what we report to a health plan is recorded, not reconstructed.
Enhanced Care Management only works when someone is accountable for the whole picture. These are the operating standards that accountability runs on.
Referring a member and contracting with Clearwater are different tasks. They should not share an inbox.
For hospitals, clinics, behavioral health and SUD programs, shelters, and health plan care teams sending a member to Clearwater.
Start a secure referralFor managed care plan network and contracting teams, county partners, and provider organizations exploring a subcontract, a standing referral relationship, or capacity in a specific service area.
See our health plan page