Clinical Research Directory

Inclusion Criteria: * Adult Medi-Cal managed care member in California. * Identified as high-risk for poor outcomes based on plan stratification or qualifying CalAIM criteria. * Eligible for ECM and at least one of the following: Transitional Care Services, Community Supports related to post-acute recovery, housing/residential stabilization, or nursing facility transition/diversion. * Recent discharge or active transition from hospital, emergency department, skilled nursing facility, post-acute facility, recuperative care, assisted living, residential behavioral health setting, or other qualifying level-of-care transition. * Able to provide informed consent, or eligible for waiver/alteration of consent if approved for cluster-level pragmatic implementation research. Exclusion Criteria: * Enrollment in hospice or expected survival less than 6 months at the time of the index episode. * Long-term custodial institutional placement without an anticipated community transition plan. * Current incarceration or detention is preventing intervention delivery. * Previous enrollment in this study during the same observation window. * Any condition that, in the investigator's judgment, makes participation infeasible or data interpretation unreliable.