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:
- Outreach and Engagement
- Comprehensive Assessment and Care Management Plan
- Enhanced Coordination of Care
- Health Promotion
- Comprehensive Transitional Care
- Member and Family Supports
- Coordination of and Referral to Community and Social Support Services
Presumptive ECM Authorizations as of January 1, 2025

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 or the Universal ECM referral form for Adult or Children/Youth.
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:
- Housing Transition Navigation Services
Members
experiencing homelessness or at risk of experiencing homelessness receive help to find, apply
for, and secure housing.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- 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.