CalAIM: Enhanced Care Management and Community Supports Services

Enhanced Care Management (ECM)

ECM is a new program that helps our Members with complex medical and social needs. These new services offer help beyond traditional medical services.  These services are provided to eligible adults, children, pregnant and/or postpartum women and justice involved individuals.

ECM helps coordinate:

  • Primary care
  • Acute care
  • Behavioral health
  • Developmental Health
  • Oral health
  • Community-based long-term services and supports (LTSS)
  • Referrals to available community resources 

ECM allows Members to have their own care team, including a Lead Care Manager (LCM) from a PCP office or a community based organization. This person 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.  

ECM services include:

  1. Outreach and Engagement
  2. Comprehensive Assessment and Care Management Plan
  3. Enhanced Coordination of Care
  4. Health Promotion
  5. Comprehensive Transitional Care
  6. Member and Family Supports
  7. Coordination of and Referral to Community and Social Support Services

How to Access ECM Services

Members are encouraged to speak with their medical providers about this benefit. To be eligible for ECM, Members must meet at least one of the populations of focus. Providers can submit a referral to ECM using this ECM Referral Form.

Community Supports (CS)

Community Supports are optional services for Medi-Cal Members that may not include direct medical care. These services are free of charge and help members with complex health issues. These health issues are often caused or made worse by lack of food, housing, or transportation.

CS services include:

  1. Housing Transition Navigation Services
    Members experiencing homelessness or at risk of experiencing homelessness receive help to find, apply for, and secure housing.

  2. Housing Deposits
    Members receive assistance with housing security deposits, utilities set-up fees, first and last month’s rent, and first month of utilities. Members can also receive funding for medically-necessary items like air conditioners, heaters, and hospital beds to ensure their new home is safe for move-in.

  3. Housing Tenancy and Sustaining Services
    Members receive support to maintain safe and stable tenancy once housing is secured, such as coordination with landlords to address issues, assistance with the annual housing recertification process, and linkage to community resources to prevent eviction.

  4. Short-Term Post Hospitalization Housing
    Members who do not have a residence, and who have high medical or mental health and substance use disorder needs, receive short-term housing for up to six months to continue their recovery. To receive this support, members must also have been discharged from an inpatient clinical setting, residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care.

  5. Recuperative Care (Medical Respite)
    Members with unstable housing who no longer require hospitalization, but still need to heal from an injury or illness, receive short-term residential care. The residential care includes housing, meals, ongoing monitoring of the member’s condition, and other services like coordination of transportation to appointments.

  6. Respite Services
    Short-term relief for caregivers of members. Members may receive caregiver services in their home or in an approved facility on an hourly, daily, or nightly basis as needed.

  7. Day Habilitation Programs
    Members who are experiencing homelessness, are at risk of experiencing homelessness, or formerly experienced homelessness, receive mentoring by a trained caregiver on the self-help, social, and adaptive skills needed to live successfully in the community. These skills include the use of public transportation, cooking, cleaning, managing personal finances, dealing with and responding appropriately to governmental agencies and personnel, and developing and maintaining interpersonal relationships. This support can be provided in a member’s home or in an out-of-home, non-facility setting.

  8. Nursing Facility Transition/Diversion to Assisted Living Facilities
    Members living at home or in a nursing facility are transferred to an assisted living facility to live in their community and avoid institutionalization in a nursing facility, when possible. Assisted living facilities provide services to establish a community facility residence such as support with daily living activities, medication oversight, and 24-hour onsite direct care staff.

  9. Community Transition Services/ Nursing Facility Transition to a Home
    Members transitioning from a nursing facility to a private residence where they will be responsible for their own expenses, receive funding for set-up services such as security deposits, set-up fees for utilities, and health-related appliances, such as air conditioners, heaters, or hospital beds.

  10. Personal Care and Homemaker Services
    Members who require assistance with Activities of Daily Living or Instrumental Activities of Daily Living receive in-home support such as bathing or feeding, meal preparation, grocery shopping, and accompaniment to medical appointments.

  11. Environmental Accessibility Adaptations (Home Modifications)
    Members receive physical modifications to their home to ensure their health and safety, and allow them to function with greater independence. Home modifications can include ramps and grab-bars, doorway widening for members who use a wheelchair, stair lifts, or making bathrooms wheelchair accessible.

  12. Medically Tailored Meals
    Members receive deliveries of nutritious, prepared meals and healthy groceries to support their health needs. Members also receive vouchers for healthy food and/or nutrition education

  13. Sobering Centers
    Members who are found to be publicly intoxicated are provided with a short-term, safe, supportive environment in which to become sober. Sobering centers provide services such as medical triage, a temporary bed, meals, substance use education and counseling, and linkage to other health care services.

  14. Asthma Remediation
    Members receive physical modifications to their home to avoid acute asthma episodes due to environmental triggers like mold. Modifications can include filtered vacuums, dehumidifiers, air filters, and ventilation improvements.

    How to Access CS Services

    Members are encouraged to speak with their ECM provider, medical providers or social service providers about this benefit. To be eligible for CS, Members must meet the criteria outlined in the CS referral form. Providers can submit a referral to CS using this CS Referral Form.