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Enhanced Care Management

Referral

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Referral

Enhanced Care Management
&
Community Support

Enhanced Care Management (ECM) is a no-cost Medicaid/Medi-Cal benefit that provides intensive, in-person care coordination for individuals with complex medical and social needs.

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Services

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               Purpose 

ECM helps bridge gaps in care by connecting patients to medical, behavioral, and social services. The goal is to improve health outcomes, reduce hospitalizations, and support long-term wellness and stability.

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How It Works

An ECM provider (like a clinic, community-based organization, or care management agency) assigns a Care Team that coordinates across all settings:

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  • Primary care and specialists

  • Behavioral health providers

  • Hospitals and emergency departments

  • Social service agencies (housing, food, transportation, etc.)

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Community Support

Community Supports are services that help improve the overall health and well-being of Medi-Cal/Medicaid managed care plan (MCP) members by addressing members’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care.

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Services include:

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  • Access to medically tailored meals to support short-term recovery

  • Transportation Services to appointments

  • Homemaker services

    These range of services and resources are designed to address the unique needs of Medi-Cal members

    in the community, with a focus on promoting health, stability, and independence.

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Population Health Management

 

  • Data-driven strategies to identify at-risk populations, close care gaps, and improve outcomes for Medi-Cal and commercial plan members.

  • Transitional Care Services (TCS)

  • Coordinating care during critical transitions—from hospital to home—to reduce readmissions and improve recovery.

  • Preventive Health & Wellness Programs

  • Community-based screenings, lifestyle coaching, and wellness education to promote long-term health.

  • Care Coordination & Case Management

  • Connecting patients to primary care, behavioral health, pharmacy, and social services to ensure holistic, continuous care
     

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