Frequently in the ER or hospital

Keep ending up in the emergency room?

If you have Medi-Cal and you have been back to the ER or hospital more than a few times lately, Atlas may be able to help. One care manager helps organize what happens between visits — follow-up appointments, medications, providers, and the barriers that keep getting in the way.

See If I Qualify Refer Someone

$0 cost to youSupport after dischargeOne care team

Call (858) 215-6887

An older adult reviewing medications at home with a visiting nurse

Are you eligible?

You may qualify if…

These are general guidelines. We'll help you understand the requirements and confirm whether you qualify.

You are 18 or older and have Medi-Cal through a managed care plan.
You have had five or more emergency department visits in the past six months that better outpatient care might have prevented.
Or you have had three or more unplanned hospital stays and/or short-term skilled nursing stays in the past six months.
No specific diagnosis is required if you meet one of those thresholds — and your health plan may also approve support if you would clearly benefit without meeting the numbers.
Help is voluntary and free to you. You can self-refer and stop at any time.

How Atlas can help

What happens between hospital visits

Atlas does not replace emergency or hospital care. We work on everything that has to happen after you leave.

Discharge turned into a plan

We translate discharge instructions into scheduled appointments, medication steps, and referrals with dates attached.

A regular doctor to go to

Connections to primary and specialty care so ongoing conditions get managed before they become emergencies.

Medication coordination

Help reconciling medications across settings and flagging access issues to the right prescriber or pharmacy.

Transitions of care

Coordination when you leave a hospital or short-term skilled nursing facility, including communication with your outpatient team.

Behavioral health

Connections to mental health and substance use support when they are part of what keeps bringing you back.

Rides to appointments

Transportation to covered medical appointments can be arranged so missed visits stop turning into ER trips.

Food, home & caregiving

Requests for authorized supports around food, housing-related needs, and caregiving that make recovery at home possible.

Everyone on the same page

We keep your health plan, hospital, doctors, and pharmacy working from the same information instead of guessing.

How it works

How it works after a hospital or ER visit

1
Get connected
A hospital, ER, skilled nursing facility, clinic, or health plan can refer you — or you can reach out yourself.
2
Review what has been happening
Your care manager looks at recent visits, diagnoses, medications, providers, and the practical barriers with you.
3
Line up the follow-up
Appointments, referrals, medication steps, and rides get organized before problems repeat.
4
Ongoing coordination
Support continues so care keeps working outside the hospital — including through any new admissions or changes.

Enhanced Care Management supports continuity and navigation; it does not replace emergency, hospital, skilled nursing, or outpatient medical services.

What to expect

What changes between visits

Here's how ongoing support can make everyday care easier and more manageable.

Follow-up appointments booked before you leave the hospital.
One medication list everyone is actually using.
A number to call before things become an emergency.
Rides, food, and home barriers addressed as part of care.

After the ER, before the next one

Let's organize what happens next.

Answer a few short questions and a real person will follow up. Prefer to talk it through? Call us — we can check together.

See If I Qualify Call (858) 215-6887

For providers, partners & anyone who wants the details

Detailed Eligibility & Program Information

The formal CalAIM / DHCS criteria for the Frequent ER Visits or Hospital Stays Population of Focus, preserved in full.

Program overview

California’s Adults At Risk for Avoidable Hospital or Emergency Department Utilization Population of Focus provides Enhanced Care Management to eligible Medi-Cal managed care members age 21 and older with repeated emergency department visits, unplanned hospital stays, or short-term skilled nursing facility stays that could potentially have been avoided through timely outpatient care, treatment follow-through, communication, or referrals. Atlas provides whole-person care management and works with the member’s health plan, hospitals, skilled nursing facilities, primary and specialty care providers, behavioral health providers, pharmacies, and community organizations to coordinate the next steps in care. Enhanced Care Management supports continuity and navigation; it does not replace emergency, hospital, skilled nursing, or outpatient medical services.

Formal eligibility criteria

Age 21 or older and enrolled in a Medi-Cal Managed Care Plan.
Had five or more emergency department visits within a six-month period that could have been avoided with appropriate outpatient care, timely intervention, care-plan development, communication, interdisciplinary coordination, referrals, or improved treatment follow-through.
Or had three or more unplanned hospital and/or short-term skilled nursing facility stays within a six-month period that could have been avoided through appropriate outpatient care or improved treatment follow-through.
No additional diagnosis, chronic condition, behavioral health condition, or social-need criterion is required when one of the numerical thresholds is met. A managed care plan may also choose to authorize ECM for another adult at risk for avoidable hospital or emergency department utilization who would benefit from ECM but does not meet the numerical thresholds.
Enhanced Care Management is voluntary. Members and families may self-refer, while final eligibility, authorization, enrollment, and provider assignment are determined through the applicable Medi-Cal managed care plan using DHCS criteria.

Whole-person assessment and personalized care plan

A Lead Care Manager works with the member to understand recent emergency visits and hospital or skilled nursing stays, current diagnoses, medications, providers, behavioral health needs, mobility, transportation, housing, food, and other priorities, then develops a person-centered care plan.

Hospital and skilled nursing transition coordination

When a member leaves a hospital or short-term skilled nursing facility, Atlas can help organize discharge information, medication lists, follow-up needs, referrals, and communication among the member, health plan, outpatient providers, and other involved care teams.

Primary, specialty, and behavioral health connections

We help coordinate referrals, appointments, and follow-up across primary care, specialty care, dental services, behavioral health, substance use treatment, home- and community-based providers, and other authorized services based on the member’s needs.

Medication and care-plan coordination

Atlas can help reconcile medication information across care settings, identify questions or access barriers for the appropriate prescriber or pharmacy, track care-plan actions, and support communication among providers. Clinical decisions remain with licensed treating professionals.

Benefits and community resource navigation

We help members request and navigate available resources for transportation, food, housing-related needs, caregiving, benefits, and other barriers that may make outpatient care harder to access. Community Supports and other programs have separate eligibility, authorization, and availability requirements.

Eligibility, authorization, provider assignment, and service availability are determined through the applicable Medi-Cal managed care plan. Medical care, transportation, Community Supports, and other programs have separate eligibility and authorization requirements and depend on local availability and member choice.

For referral partners

Refer a member with repeat ER or hospital use

Refer an adult with repeated emergency department visits, unplanned hospital stays, or short-term skilled nursing facility stays who may meet the DHCS criteria or otherwise be considered by the health plan for Enhanced Care Management. Referrals may come from Medi-Cal managed care plans, hospitals, emergency departments, skilled nursing facilities, primary and specialty care practices, behavioral health providers, pharmacies, community organizations, members, and families.

Refer a Member (858) 215-6887

Hospitals & emergency departments
Skilled nursing facilities
Primary & specialty care
Behavioral health providers
Pharmacies
Medi-Cal health plans

Partners can also reach the Atlas team directly to discuss workflows, referral coordination, and data sharing agreements. Partner information

Other populations of focus