Enhanced Care Management (ECH)

CalAIM Enhanced Care Management (ECM) — Complete Benefits Description

What Is ECM?

ECM is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of members with the most complex medical and social needs. ECM provides systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered. DHCS' vision for ECM is to coordinate all care for members who receive it, including across the physical and behavioral health delivery systems. Hpsj

ECM meets members wherever they are — on the street, in a shelter, in their doctor's office, or at home. Members have a single Lead Care Manager who coordinates care and services among the physical, behavioral, dental, developmental, and social services delivery systems, making it easier for them to get the right care at the right time. CA

ECM is free of charge for all eligible Medi-Cal managed care members who qualify.

👤 The Lead Care Manager — Your Personal Health Navigator

At the heart of ECM is a dedicated Lead Care Manager (LCM), a single point of contact responsible for coordinating all aspects of a member's care. The Lead Care Manager will talk to members and their doctors, specialists, pharmacists, case managers, social services providers, and others to make sure everyone works together to get them the care they need. The LCM can also help members find and apply for other services in their community. Community Health Group

🔑 The Seven Core ECM Service Benefits

ECM is comprised of seven core service areas available to enrolled members. Here is a full description of each: Healthnetcalifornia

1. Outreach and Engagement

Outreach and engagement includes active and progressive attempts to connect with and engage with members who are eligible, demonstrating a culturally and linguistically competent approach to build trust. This includes: San Francisco Health Plan

Meeting members where they live — on the street, in encampments, shelters, clinics, jails, and hospitals

Persistent, patient-centered outreach until contact is established

Culturally and linguistically appropriate engagement

Building trust with members who may have had negative healthcare experiences in the past

Warm introductions to the care team and program

2. Comprehensive Assessment and Care Management Plan

Following successful engagement with the member, ECM Care Managers complete a comprehensive biopsychosocial assessment of member needs and engage the member in creation of a person-centered care plan that outlines the member's strengths, risks, needs, and goals. This includes: San Francisco Health Plan

Full assessment of physical health, behavioral health, social needs, housing, nutrition, and safety

Identification of barriers to care

Creation of a personalized, member-directed care management plan

Regular reassessment and updates to the care plan as needs change

Integration of the member's own goals and priorities into every plan

3. Enhanced Coordination of Care

Enhanced Coordination of Care includes the services necessary to implement the care plan, ensuring care is continuous and integrated among all service providers. ECM Care Managers support coordination across the continuum of care, including primary care, physical and developmental health, mental health, SUD treatment, long-term services and supports (LTSS), oral health, and palliative care. This includes: San Francisco Health Plan

Scheduling and following up on medical, dental, and behavioral health appointments

Communicating between all providers on the member's behalf

Ensuring no duplication or gaps in services

Coordinating with specialists, hospitals, skilled nursing facilities, and community organizations

Supporting continuity of care during transitions between settings

4. Health Promotion

This benefit focuses on preventing illness, improving wellness, and empowering members to take charge of their own health. Services include:

Education about chronic disease self-management (diabetes, hypertension, asthma, HIV, etc.)

Medication education and adherence support

Preventive care reminders and follow-through (screenings, immunizations, annual wellness visits)

Healthy lifestyle support — nutrition, physical activity, smoking cessation

Connection to community health education resources and classes

Addressing health literacy barriers

5. Comprehensive Transitional Care

This is a critical benefit that supports members moving between different care settings to prevent readmissions and ensure continuity. Assistance may be provided in finding physicians, scheduling medical appointments, managing medications, and locating and applying for needed community-based services and supports. Specific transitional care services include: Medicaid Planning Assistance

Coordinating safe discharges from hospitals, skilled nursing facilities, recuperative care, and psychiatric facilities

Bridging the member to the next level of care with warm handoffs

Medication reconciliation after discharge

Follow-up visits within 30 days of discharge to prevent readmission

Pre-release coordination for members leaving jails and prisons

Support transitioning from foster care, institutional settings, and residential facilities

6. Member and Family Supports

ECM recognizes that members do not exist in isolation — their families and support networks are essential to recovery and stability. Benefits include:

Education and support for caregivers and family members

Assistance navigating complex health and social service systems as a family unit

Support for parents, guardians, and caregivers of children with complex needs

Help establishing legal guardianship or accessing family support services

Connection to respite care for caregivers when needed

Perinatal support for pregnant and postpartum members

7. Coordination of and Referral to Community and Social Support Services

ECM provides personalized care management to eligible members, coordinating all aspects of a member's care across physical and behavioral health delivery systems. This seventh core component specifically addresses social determinants of health by connecting members to: CA

Housing — referrals to Housing Transition Navigation, Housing Deposits, Transitional Rent, and Tenancy Sustaining Services

Food security — CalFresh enrollment, food banks, medically tailored meals

Income and benefits — SSI/SSP, General Relief, CalWORKs, disability applications

Transportation — Medi-Cal transportation benefits and non-emergency medical transport

Legal services — help with civil legal issues that affect health

Employment and education — connection to workforce development programs

Domestic violence and safety — referrals to shelter and survivor services

Substance use and mental health treatment — warm referrals to outpatient and inpatient programs