calAIM

CalAIM
California Advancing and​ Innovating Medi-Cal

Learn more about CalAIM by visiting Department of Health Care Services (DHCS) website here.

To learn more about ECM and CS, visit:

Enhanced Care Management (ECM)

The ECM benefit is designed to provide a whole-person approach to care that addresses both clinical and non-clinical needs for high need Medi-Cal beneficiaries.

What is the purpose of ECM?
ECM is intended to:
  • Improve care coordination and integrate services through:
    • Person-centered, goal oriented and culturally relevant care to ensure members receive needed services in a supportive, effective, efficient, timely and cost-effective manner
    • Face-to-face member visits, when possible, to coordinate all primary, acute, behavioral, developmental, oral, and long-term services and supports
    • Keep doctors updated on member health needs and wishes
    • Understand medication needs and how to access refills
  • Address social determinants of health and connect members to needed community and social services through assessment and referral to CS as appropriate
Who qualifies for ECM?

To refer a patient for ECM services, see, ECM Referrals tab. To request ECM services, complete ECM Eligibility Verification Form. To submit an authorization request, please login to our provider portal or click here to submit by fax.

January 1, 2022

San Joaquin County

  • Adults and their Families Experiencing Homelessness
  • Adults At Risk for Avoidable Hospital or Emergency Department (EDO) Utilization (formerly “High Utilizers)
  • Adults with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
  • Individuals Transitioning from Incarceration (some Whole Person Care (WPC) counties)
  • Adults with Intellectual or Developmental Disabilities (I/DD)
  • Pregnant or Postpartum Adults
July 1, 2022 Stanislaus County
  • Adults and Families Experiencing Homelessness
  • Adults at Risk for Avoidable Hospital or ED Utilization
  • Adults with Serious Mental Health and/or SUD Needs
  • Adults with Intellectual or Developmental Disabilities (I/DD)
  • Pregnant or Postpartum Adults
January 1, 2023
  • Adults Living in the Community and At Risk for Long Term Care (LTC) Institutionalization
  • Adults Nursing Facility Residents Transitioning to the Community
July 1, 2023
  • Adults without Dependent Children/Youth Living with Them Experiencing Homelessness
  • Children and Youth Populations of Focus
    • Homeless Families or Unaccompanied Children/Youth Experiencing Homelessness
    • Children and Youth At Risk for Avoidable Hospital or ED Utilization
    • Children and Youth with Serious Mental Health and/or SUD Needs
    • Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
    • Children and Youth Involved in Child Welfare
    • Pregnant or Postpartum Youth
January 1, 2024
  • Pregnant and Postpartum Individuals At Risk for Adverse Perinatal Outcomes who are subject to racial and ethnic disparities
January 1, 2024
  • Individuals Transitioning from Incarceration
What is an ECM Lead Care Manager?
ECM providers assign members a Lead Care Manager. They are a part of their care team. They help coordinate care between:
  • Members
  • Their doctors
  • Specialists
  • Pharmacists
  • Case managers
  • Social Services providers
  • Others
A Lead Care Manager can also help members find and apply for other services in the community.
ECM Referrals
Referrals for ECM or Community Supports may come from multiple sources, such as: Referrals for ECM
  • ECM Providers or Community Support Providers* follow the process outlined during training. For any questions, please call HPSJ Customer Service at 888.936.7526.
  • Primary Care Providers or Community Based Organizations*- please complete the ECM Referral Form and fax it to HPSJ Case Management Department at 209.762.4720.
  • Member, Family, or Caregiver* may call HPSJ Customer Service at 888.936.7526.
  • Hospitals and Facilities* request an ECM referral through the standard communications with their HPSJ Concurrent Review nurse or Transition of Care staff.
*Members must meet specific criteria to be eligible for these services. The ECM Referral Form includes a summary of criteria.
DHCS Enhanced Care Management Policy Guide

Community Supports (CS)

Community Supports (CS), previously known as In Lieu of Services or ILOS, are medically appropriate and cost-effective services. ECM members may qualify for CS however CS is not restricted solely to members receiving ECM, and other members may be eligible.

What community supports does HPSJ offer?
HPSJ is offering the following community supports in San Joaquin and Stanislaus counties:
  • Housing Transition Navigation Services: assistance to obtain housing. This may include assistance with searching for housing or completing any housing applications if appropriate and authorized by HPSJ.
  • Housing Deposits: HPSJ to provide one-time funding to establish basic housing, including assistance with security deposits to obtain a lease or assisting with first month’s coverage of utilities or rent.
  • Housing Tenancy and Sustaining Services: assistance helping residents keep safe and stable housing once housing is secured.
  • Short-Term Post Hospitalization Housing: provides those that do not have a residence, and who have a high medical or behavioral health needs, a place to recover after a hospital or facility stay.
  • Recuperative Care (Medical Respite): short term housing for those who no longer require hospitalization but need to heal from an injury or illness.
  • Medically Tailored Meals/Medically-Supportive Food: meals that are delivered to the home that are tailored to meet members dietary needs.
  • Sobering Center: an alternate, short-term location to sober for those who are found to be under the influence in public and would otherwise be transported to emergency services or jail.
  • Asthma Remediation: physical changes to the home that are necessary to help members live in the home without environment or asthma-related triggers.
  • Environmental Accessibility Adaptations (Home Modifications): physical changes to the home to allow individual to function with greater independence and not require care in a nursing facility.
  • Day Habilitation Programs: Programs designed to provide the member in obtaining and improving self-help, social skills, and adaptive skills to live successfully in a natural environment.
  • Personal Care and Homemaker Services: Services provided to individuals who need assistance with activities of daily life like bathing, dressing, feeding, housekeeping, or grocery shopping.
  • Respite Services: Short-term services provided to caregivers of those who require occasional temporary supervision to give relief to the caregiver.
  • Nursing Facility Transition/Diversion to Assisted Living Facilities: Services to help members live in the community and avoid nursing facility stays when possible.
  • Community Transition Services/Nursing Facility Transition to a Home: Services to help members live in the community and avoid further institutionalization by providing non-recurring set up expenses for individuals transitioning from a licensed facility to a living arrangement in a private residence

For members delegated to Kaiser, Kaiser will maintain responsibility to provide Community Supports for Kaiser members. Please refer to Kaiser Evidence of Coverage for available community supports. If a Kaiser-assigned member wishes to receive other community supports offered by HPSJ and not offered by Kaiser; they may access by choosing reassignment to HPSJ by contacting Customer Service at 1.888.936.PLAN (7526), TTY/TDD 711.
CS Referrals
Referrals for ECM or Community Supports may come from multiple sources, such as:
  • ECM Providers or Community Support Providers
  • Primary Care Providers or Community Based Organizations
  • Member Self or Family Referrals
  • Hospitals and Facilities
Referrals for Community Supports

Prior Authorization Form

  • ECM Providers or Community Support Providers* follow the process outlined during training. For any questions, please call HPSJ Customer Service at 888.936.7526.
  • Primary Care Providers or Community Based Organizations*- please complete the CSS Referral Form and fax it to HPSJ Case Management Department at 209.762.4720.
  • Member, Family, or Caregiver* may call HPSJ Customer Service at 888.936.7526.
  • Hospitals and Facilities* may request a Community Support Service through the standard communications with their HPSJ Concurrent Review nurse or Transition of Care staff.
*Members must meet specific criteria to be eligible for these services.
DHCS Community Supports Policy Guide
CS Referral Form
You can download the Community Support Services Referral Form using the link below:
Community Support Services Referral Form

Long Term Care (LTC)

Topics covered on LTC page:
  • Types of Long-Term Care Facilities
  • Long Term Care Benefit Overview
  • The Preadmission Screening Resident Review (PASRR)
  • Non-Emergency Medical Transportation (NEMT) for members in Long Term Care
View Long Term Care Page

ICF/Sub Acute Services

Topics covered on ICF/Sub Acute Services & Support page:
  • ICF/Sub Acute Service Overview
  • DME/Prior Authorization
  • Case Management
  • Authorization Timeline/Documentation needed for Authorizations
View ICF/Sub Acute Services & Support Page

Become a Contracted Provider

Join Our Network

CalHHS Emergency Resource Guide

Posted on May 23rd, 2023 and last modified on February 12th, 2024.

top
X