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?

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 Children and Youth with I/DD 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
2024 (Date TBD)	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:

ECM Providers or Community Support Providers
Primary Care Providers or Community Based Organizations
Member Self or Family Referrals
Hospitals and Facilities

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
Housing Deposits
Housing Tenancy and Sustaining Services
Short-Term Post Hospitalization Housing
Recuperative Care
Medically Tailored Meals/Medically-Supportive Food
Sobering Center
Asthma Remediation
Environmental Accessibility Adaptations (Home Modifications)
Day Habilitation Programs
Personal Care and Homemaker Services
Respite Services
Nursing Facility Transition/Diversion to Assisted Living Facilities (Effective July 2023)
Community Transition Services/Nursing Facility Transition to a Home (Effective July 2023)

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

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

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CalAIM
California Advancing and Innovating Medi-Cal