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Enhanced Care Management

We’re vastly improving health outcomes for high-need members by providing comprehensive care that goes beyond the hospital or doctor’s office. We’re breaking down the traditional walls of healthcare to improve the overall well being and quality of life

What is the Enhanced Care Management program?

Enhanced Care Management (ECM) is a free statewide Medi-Cal support service available to qualifying members with complex health and social needs as part of the DHCS’ CalAIM (Advancing and Improving Medi-Cal) program.

If you or someone you know might benefit from this program, please call us for more information or fill out our referral form.

Enhanced Care Management Helpline : 800-437-3168. 

Transforming the complex needs of Medi-Cal members

Medi-Cal members often have multiple complex physical, behavioral, and social conditions.

Members with complex needs often need to engage multiple delivery systems to access care, such as: primary and specialty care, mental health, substance use disorder treatment, dental, vision, and longterm care services.

More than half of Medi-Cal spending is attributed to the 5 percent of members with the highest-cost needs.

ECM is a key part of Medi-Cal’s transformation to ensure that people get the care they need. It breaks down the traditional walls of health care to extend care into members’ communities. This creates a more coordinated, person centered, and equitable health system with better outcomes for everyone.

How does the ECM program work?

The program provides care management services directly to members from a dedicated Lead Care Manager (LCM) who coordinates all of their healthcare related needs and social services—advocating on their behalf while offering guidance, support and resources. LCMs establish high-trust and language-appropriate relationships with their members. LCMs meet members where they are, whether it’s at a coffee shop, a doctor’s appointment, at their home, shelter, or via phone or video call.

What are the services that ECM provides?

Enhanced Care Management helps Medi-Cal members in many ways:

Doctors

Coordination care

Rx

Food

Housing

Dental and Eye care

Medical Supplies

Mental Health

Transportation

Follow-up care

For Hospitals, Health Plans and IPA’s

California Advancing and Innovating Medi-Cal (CalAIM)

The CalAIM initiative is a statewide commitment to:

  • Identify and manage the comprehensive needs of Medi-Cal members through a whole-person care approach and by addressing social drivers of health.

  • Improve health outcomes, reduce disparities, and transform the healthcare delivery system through value-based care models, system modernization, and payment reform.

  • Create a more seamless and accessible Medi-Cal system by reducing complexity and increasing flexibility for enrollees.

 

Art of Palliative Healthcare's Participation in CalAIM

Art of Palliative Healthcare participates in two key CalAIM programs:

  1. Enhanced Care Management (ECM) Program
    This program focuses on addressing Social Determinants of Health (SDOH) by coordinating comprehensive care for Medi-Cal members with complex medical, behavioral, and social needs.

  2. Community Supports (CS) Program
    This program addresses housing instability and homelessness, offering non-clinical services to support members in achieving better health outcomes through stable living environments.

 

How Can Hospitals and IPAs Get Involved?

When hospitals and IPAs partner with Art of Palliative Healthcare, they gain access to valuable support services through the CalAIM initiative. Benefits include, but are not limited to:

  1. Providing long-term housing options for homeless patients

  2. Addressing key social issues for high-utilizing members, such as food insecurity

  3. Reducing ED and inpatient bed occupancy by facilitating safe and timely discharges for homeless patients

  4. Reducing delays in transfer for members with serious mental illness (SMI), easing the burden on hospital capacity

The ECM and CS programs are not short-term fixes—they represent sustainable, long-term solutions. Partnering with an ECM provider like Art of Palliative Healthcare not only improves member outcomes but also enhances the operational efficiency of hospitals and IPAs.

Why ECM matters?

Lower Costs, Healthier Lives

The Enhanced Care Management program reduces healthcare costs by delivering proactive, coordinated care that keeps people healthier and out of high-cost settings. By focusing on whole-person care, improving care coordination, and connecting individuals to essential community support services, ECM helps prevent avoidable emergency room visits and hospital readmissions—ultimately easing the financial burden on the healthcare system.

What are the services that ECM provides?

Enhanced Care Management helps Medi-Cal members in many ways:

Improved Care Coordination

Dedicated Care Managers

Each eligible member is assigned a Lead Care Manager who works with them and their other providers to coordinate their care across different health systems.

We figure out what is not working and do something about it.

Comprehensive Assessments

Lead Care Managers conduct thorough assessments to identify all needs, including medical, behavioral, and social factors, and develop individualized care plans. This assessment becomes the basis for the relationship with Titanium.

Reduced Hospital Admissions (37% reduction)

Art of Palliative Healthcare is committed to identifying and addressing the root causes behind patient admissions. Often, repeat hospitalizations can be prevented by understanding the underlying issues driving them.

Our team provides comprehensive follow-up care after hospital discharge, focusing on critical transition needs. This includes assistance with discharge planning, medication support, and connecting patients to essential community resources. By prioritizing this vulnerable period, we help ensure a smoother recovery process and significantly reduce the likelihood of readmission.

Early Intervention

By identifying individuals at risk for hospital admissions early on, we can intervene and prevent these admissions from occurring.

25% Drop in Emergency Room Visits with ECM Program

We dig deep to understand the root causes behind repeated emergency room visits. These unnecessary visits aren’t just costly to the healthcare system—they often reflect deeper issues that leave patients feeling frustrated and unwell. By identifying patterns and addressing the underlying factors driving ER use, we deliver targeted, compassionate care that keeps people healthier and out of crisis.

Community-Based Care

We’re providing care in the community – right where its needed, reducing the need for expensive institutional care like nursing facilities.

Access to resources

The ECM Program connects members with community-based resources and services that can help them manage their health and well-being.

Shift in Focus to Preventative Care

Focus on Well-being

The ECM Program prioritizes preventing health problems and improving overall well-being, leading to fewer costly interventions later on.

The Enhanced Care Management (ECM) program has a transformative impact. Providing Medi-Cal members with dedicated support and guidance through their healthcare journey significantly improves their overall experience and outcomes.

©2021 by Art of Palliative Care. 

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