Enhanced Care Management is a statewide Medi-Cal benefit available to select members with complex health needs. Enrolled members receive comprehensive care management from a single lead care manager who coordinates all their health and health-related care. This could include help with medical conditions, mental health, or basic activities of daily living. Enhanced Care Management makes it easier for members to get the right care at the right time in the right setting, and receive comprehensive care that goes beyond the doctor’s office or hospital.
At Partners in Care Foundation, we are proud to be accredited by the National Committee for Quality Assurance (NCQA) for case management in long-term services and supports. Our care coordinators in ECM are here to assist individuals in finding local doctors and healthcare providers, scheduling appointments, connecting to transportation services, and helping with finding food, housing, and other essential services—among many other forms of support.
Who is Eligible for ECM?
To get ECM services, individuals must be enrolled in Medi-Cal and meet certain eligibility requirements.
Children, youth, and adults may qualify if they have any of the following:
- Homelessness and health or mental health needs
- Frequent hospital or emergency room visits
- Mental health or substance use support
- Risk of long-term hospital or nursing home stays
- Living in a nursing home but wanting to return to the community
- Involvement in Child Welfare services
- Chronic health condition
Partners’ ECM provides all core services delineated by the California Department of Health Care Services (DHCS):
- Outreach and Engagement
- Comprehensive Assessment and Care Management Plan
- Enhanced Coordination of Care
- Health Promotion
- Comprehensive Transitional Care
- Individual and Family Support
- Coordination of and Referral to Community and Social Support Services
Partners’ ECM Model of Care
- Full Model of Care – Long-term coordination for multiple chronic conditions, social determinants of health issues, and utilization of multiple service types and delivery systems
- Full Clinical Care Coordination – MCO, PCP, FQHC, Homeless Service Providers, Mental Health, Drug Treatment – strong care transitions experience
- Proven results
- Deep knowledge of community resources and relationships with them to get real connections, not just referrals
- In-person/home visits wherever and whenever possible
- Blended Staffing Model using most appropriate skill level (RN, LCSW, MSW, BSW, CHW’s)
- Timely and Accurate data collection and reporting –Salesforce Intake, Outreach & Engagement, Care Management, Analytics/Data, Reporting Tools, Auditing Tools, Encounter Data
- Partners is NCQA accredited
- Utilization of Collective Medical’s Emergency Room patient data
- Evidence-based, In-home medication use analysis with HomeMeds®
- Partner with the Homeless Management Information System (HMIS) and services to expedite homeless members in entering the Coordinated Entry System (CES)
- Primary reliance on evidence-based tools – especially for chronic disease self-management
- Motivational Interviewing
- Problem Solving Treatment for Primary Care (PST-PC)
- Behavioral Activation
- Fall prevention
- Chronic pain and chronic disease management, such as for arthritis, diabetes, and related conditions
Contact Us:
To make a direct referral or request additional information, please email ECM@picf.org and include “ECM Inquiry” in the subject line