Enhanced Care Management (ECM) and Community Supports (CS)

CalAIM is a statewide California Department of Health Care Services (DHCS) multi-year initiative that builds upon the Whole Person Care (WPC) Pilot and Health Homes Program (HHP). It is designed to implement a broad delivery system, program, and payment reform across the Medi-Cal program with the ultimate long-term goal of a better quality of life for all Medi-Cal members.

Enhanced Care Management (ECM)

Enhanced Care Management (ECM) is a benefit that provides extra care coordination services to members with highly complex needs. Members who qualify for ECM will have their own care team, including care coordinators, doctors, specialists, pharmacists, case managers, social service workers, and others to make sure everyone works together. ECM also includes:

  • Comprehensive assessment and care management
  • Comprehensive transitional care
  • Coordination and referral to community and social supports
  • Enhanced coordination of care
  • Health promotion
  • Member and family support services
  • Outreach and engagement

ECM will be offered to members who meet at least one of the ECM Populations of Focus definitions described below. The Alliance may contact the member directly about ECM if the member qualifies.

Populations of Focus:

  • Individuals Experiencing Homelessness:
    • Adults without dependent children/youth living with them experiencing homelessness.
    • Homeless families or unaccompanied children/youth experiencing homelessness.
  • Individuals at risk for avoidable hospital or emergency department (ED) utilization (formerly known as ‘High Utilizers’)
  • Individuals with serious mental health and/or substance use disorder (SUD) needs
  • Adults living in the community and at risk for long-term care
  • Adult nursing facility residents transitioning to the community.
  • Children and youth enrolled in California’s Children Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS
  • Children and youth involved in child
  • Birth equity population of focus

How to Enroll

  • If you believe that your patient may be appropriate for ECM services, please complete the ECM Approval Request Form.
  • An ECM Provider may contact the member directly to find out if the member would like to enroll.
  • The member may also self-refer by calling:

Alliance Case and Disease Management Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4512
Toll-Free: 1.877.251.9612
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

Community Supports (CS)

Community Supports (CS) are medically appropriate, cost-effective alternatives to those services covered under the Medi-Cal State Plan. These services are optional and may help members live more independently but do not replace benefits that they already get under Medi-Cal. The Alliance is currently offering the following CS services:

  • Housing Transitions Navigation Services
    • Assists members with obtaining housing.
  • Housing Deposits
    • Assists members with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a member to establish a basic household (that do not constitute room and board).
  • Housing Tenancy and Sustaining Services
    • Assists members with providing tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured.
  • Recuperative Care (Medical Respite)
    • Short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable environment.
  • Medically Tailored Meals/Medically-Supportive Food
    • Meals provided/delivered to the home that meet the unique dietary needs of those with chronic conditions, immediately following discharge from a hospital or nursing home.
  • Asthma Remediation
    • Physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable to individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization.
  • (Caregiver) Respite Services
    • Assists members (and their caregivers) by providing relief support to caregivers, while continuing to serve members who live in the community and are compromised in their activities of daily living (ADLs).
  • Personal Care & Homemaker Services
    • Assists individuals who are approved (or in process) for In-Home Supportive Services.
  • Environmental Accessibility Adaptations (Home Modifications)
    • Assists members who require physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual, without which the member would require institutionalization.

Starting Monday, January 1, 2024, the Alliance will go live with the following Community Supports Services:

  • Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly and Adult Residential Facilities
    • Assists individuals to live in the community and/or avoid institutionalization when possible.
  • Community Transition Services/Nursing Facility Transition to a Home
    • Helps individuals to live in the community and avoid further institutionalization.
  • Sober Centers
    • Alternative destinations for members who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency room or jail.

Members can be referred for ECM and CS by their provider to:

Alliance Case Management Department
Monday – Friday, 8 am – 5 pm
Phone Number: 1.510.747.4512
Toll-Free: 1.877.251.9612
People with hearing and speaking impairments (CRS/TTY): 711/1.800.735.2929

To see provider FAQs, please click here.

For more provider updates, please see provider manual.