When Celia, a 45-year-old farmworker in Central California, was discharged from the hospital after five months of life-threatening complications, she returned home confused, in pain, and unsure how to care for her open surgical wound. She didn’t understand her treatment instructions, missed key appointments, and struggled with breathing. On top of it all, she spoke primarily Mixteco Bajo and had no reliable access to transportation, groceries, or follow-up care.
But then, she was connected to Lizbeth—a dedicated care manager through Community Bridges’ Enhanced Care Management (ECM) program.
“Thank God for putting this program in my path,” Celia says now. “And Lizbeth, too. Now I feel free, my wound has been closed and healed, I can walk well again, and I am not agitated anymore.”
Stories like Celia’s are what ECM is all about: empowering Medi-Cal recipients with complex health and social needs to get the personalized support they need to heal and thrive.
What Is ECM?
ECM is a free Medi-Cal benefit that provides one-on-one support for individuals with complex needs. As part of California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, ECM is designed to create a more equitable, person-centered healthcare system—especially for those most at risk of falling through the cracks.
Through ECM, clients are paired with a care manager who:
- Works with the family and healthcare provider to build a personalized plan of care
- Takes time to listen, understand and educate themselves on the member’s condition
- Helps schedule and ensures member attends medical or mental health appointments
- Connects them to resources like housing support or food access
- Arranges transportation and interpreters
- Coordinates services across providers
- Builds trust, offers guidance, and walks alongside them through their journey
In Santa Cruz, Monterey, San Benito, Mariposa, and Merced Counties, ECM is provided through the Central California Alliance for Health (The Alliance), the region’s Medi-Cal managed care plan. Community Bridges is a trusted local ECM provider, offering compassionate, high-touch care coordination that meets people where they are—whether that’s in their home, at the clinic, or recovering from a hospital stay.
In Celia’s case, her care manager:
- Met her weekly at the wound care clinic
- Scheduled appointments with a dietitian
- Arranged delivered groceries and Medi-Cal transportation
- Accompanied her to UCSF for respiratory evaluation
- Connected her to healthcare resources
- Helped her navigate housing and renew CalFresh
- Taught her how to make her own appointments and request services
- Ordered her medical alert bracelet and supported medication management
Just a few months after enrolling in ECM, Celia’s wound had closed, her breathing improved, and she’d regained confidence in managing her own care.
Who Qualifies for ECM?
ECM is available, AT NO COST, to Medi-Cal members facing one or more of the following challenges:
- People and families experiencing homelessness: For people without stable housing or living in shelters, vehicles, encampments, or other temporary situations.
- People at risk for frequent hospital or emergency department (ED) visits: For those with complex physical or behavioral health conditions that often result in repeated hospital or ER use.
- Adults with serious mental illness (SMI) or substance use disorder (SUD): For those living with mental health or substance use challenges that impact their well-being and daily functioning.
- Individuals with intellectual or developmental disabilities: Eligible if they also meet criteria for homelessness, frequent hospital use, or have SMI/SUD.
- Individuals at risk of institutionalization and eligible for long-term care: For those who may require nursing home-level care without proper in-home or community-based support.
- Nursing facility residents transitioning to the community: For individuals leaving nursing homes and moving back to independent or supported living settings.
- Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model with additional needs: For children with complex, chronic health conditions requiring specialized care.
- Children involved in child welfare: For foster children or those involved with child protective services who have high physical, behavioral, or developmental needs.
- Pregnant and postpartum individuals: For those facing health, social, or environmental risks during pregnancy and after childbirth.
- Individuals experiencing birth inequities: For people at higher risk of poor birth outcomes due to systemic health disparities.
- Individuals transitioning from incarceration: For those recently released from jail, prison, or juvenile facilities who need help reintegrating into the community with healthcare and social support.
If you or someone you know fits into one of these categories, ECM may be the support system that can make all the difference.
Need A Little Extra Support?
If you think you or someone you know may qualify for ECM services, we’re here to help.
Call us at: 831-688-8840 ext. 4020
Email: susiev@cbridges.org
Apply online: CommunityBridges.org/enhanced-care-management/
You can also speak with your doctor or care provider about a referral.
