Enhanced Care Management (ECM) Model of Care

On January 1, 2022, the State of California changed the way it provides services to residents who had been receiving services through the Health Homes program. Now, services for those individuals are offered through the Enhanced Care Management (ECM) program. This change is part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative that has been underway since 2020.

The Department of Health Care Services describes Cal AIM as “a multi-year initiative by DHCS to improve the quality of life and health outcomes of our population by implementing broad delivery system, program and payment reform across the Medi-Cal program.”

Who qualifies for Enhanced Care Management services? They are available to individuals with Medi-Cal managed care benefits who meet both chronic health related and acuity-based criteria. ECM services address the clinical and non-clinical needs of individuals through the coordination of services and comprehensive care management. 

Partners is proud of the ECM model our staff has put together in response to the state’s new requirements for services. It is based on deep experience caring for Medi-Cal participants who are typically very frail, very poor, and disadvantaged in many ways. We believe the model is a perfect reflection of our mission to align statement that says we “align social care and health care to address the social determinants of health and equity disparities affecting diverse, under-served and vulnerable populations.”

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

Our Model of Care

  1. 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
  2. Full Clinical Care Coordination – MCO, PCP, FQHC, Homeless Service Providers, Mental Health, Drug Treatment – strong care transitions experience
  3. Proven results
  4. Deep knowledge of community resources and relationships with them to get real connections, not just referrals
  5. In-person/home visits wherever and whenever possible
  6. Blended Staffing Model using most appropriate skill level (RN, LCSW, MSW, BSW, CHW’s)
  7. Timely and Accurate data collection and reporting –Salesforce Intake, Outreach & Engagement, Care Management, Analytics/Data, Reporting Tools, Auditing Tools, Encounter Data
  8. Partners is NCQA accredited
  9. Utilization of Collective Medical’s Emergency Room patient data
  10. Evidence-based, In-home medication use analysis with HomeMeds®
  11. Partner with the Homeless Management Information System (HMIS) and services to expedite homeless members in entering the Coordinated Entry System (CES)
  12. 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

ECM Service Stories

Connecting a Homeless Senior Living With Complex Medical Conditions With Housing

Contact Us:

To make a direct referral or request additional information, please email ECM@picf.org and include “ECM Inquiry” in the subject line