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Learn More about ECM Page Content Guide

Enhanced Care Management (ECM)

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Real support for complex needs

Enhanced Care Management (ECM) is a Medi-Cal benefit designed for individuals with the most complex health and social needs. It provides ongoing, coordinated support to help individuals stay stable, connected, and supported over time.

At The Link Family Resource Center, ECM means you are not navigating systems alone. You will have a dedicated Lead Care Manager helping you every step of the way.

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What ECM Helps With

ECM focuses on addressing the root causes of instability, not just immediate needs.

We help with:

• Housing and homelessness support
• Food access and basic needs
• Medical and behavioral health coordination
• Transportation barriers
• School and family support
• Ongoing follow-up so you don’t feel lost or forgotten

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Who Qualifies for ECM

ECM is for Medi-Cal (CenCal Health) members who meet at least one Population of Focus.

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Core Eligibility Examples

You may qualify if you are:

• Experiencing homelessness or at risk of losing housing
• Living with serious mental health or emotional challenges
• Living with substance use disorder and need recovery support
• Managing multiple chronic health conditions (e.g., diabetes, heart disease)

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Full Populations of Focus (CalAIM ECM)

To ensure clarity for staff, referrals, and billing alignment, here is the complete ECM Population of Focus list:

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Adult Populations

• Individuals experiencing homelessness
• Individuals at risk of avoidable hospital or emergency room use
• Individuals with serious mental health and/or substance use disorder needs
• Individuals transitioning from incarceration
• Adults living in the community at risk of long-term care institutionalization
• Adult nursing facility residents transitioning back to the community
• Individuals with intellectual or developmental disabilities (I/DD)
• Pregnant and postpartum individuals / birth equity population

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Children & Youth Populations

• Children and youth experiencing homelessness
• Children and youth involved in child welfare
• Children and youth with serious mental health or substance use needs
• Children and youth at risk of avoidable hospital use
• Children and youth transitioning from incarceration
• Children and youth enrolled in California Children’s Services (CCS) with additional needs

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Additional State-Recognized Focus Areas

• Individuals and families with complex, overlapping medical, behavioral, and social needs
• Individuals impacted by health disparities (birth equity population) (Anthem)

 

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What You Receive in ECM

1. Dedicated Lead Care Manager   Note: 

You will have one main point of contact who helps coordinate everything.

2. Personalized Care Plan   Note: 

We build a plan based on your real-life needs, goals, and strengths.

3. Care Coordination  Note: 

We connect and communicate with:

• Doctors
• Behavioral health providers
• Schools
• Social services
• Community programs

4. Ongoing Support (Not One-Time Help)  Note: 

ECM includes consistent follow-up and engagement, not just referrals.

5. Whole-Person Approach  Note: 

We address:

• Physical health
• Mental health
• Social needs (housing, food, safety)

 

 

How the Process Works (Clear Workflow)  Note: 

This aligns directly with ECM operations and helps both families and staff understand the flow:

Step 1: Referral or Interest  Note: 

Submit a referral or contact our team.

Step 2: Eligibility Review  Note: 

We verify Medi-Cal and Population of Focus.

Step 3: Enrollment (Authorization)  Note: 

If eligible, services are approved.

Step 4: Assessment (Within 30 Days)  Note: 

We complete a full assessment of needs.

Step 5: Care Plan (Within 60 Days)  Note: 

We build a structured plan with goals and services.

Step 6: Ongoing Monthly Support  Note: 

Based on acuity:

• High: frequent contact
• Moderate: regular contact
• Low: consistent check-ins

 

Get Connected  Note: 

If you or someone you know may benefit from ECM, we’re here to help.

The Link Family Resource Center
Lead Care Manager: Carmen Del Real
📞 805-503-9638
📧 cdelreal@linkslo.org

 

 

Closing Statement  Note: 

You do not have to manage everything on your own.
Enhanced Care Management provides consistent, coordinated, and long-term support to help you move toward stability, health, and well-being.

 

Referral / Interest Form (Website Section)   Note: 

Interested in ECM Services?

Please complete the form below:

Required Fields (aligned with ECM workflow):  Note: 

• Full Name
• Date of Birth
• Medi-Cal Number (or last 4 SSN)
• Phone Number
• Preferred Language (spoken + written)
• Address or Housing Status
• Population of Focus (if known)
• Current Needs / Reason for Referral
• Best Time to Contact