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:
- Helps schedule and attend 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, 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
- 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:
- Multiple chronic health conditions (e.g., diabetes, heart disease)
- Serious mental illness or substance use disorder
- Homelessness or unstable housing
- Involvement with child welfare
- Recent release from incarceration
- Transitioning from a long-term care facility
If you or someone you know fits into one of these categories, ECM may be the support system that can make all the difference.
How Do I Get Started?
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: StevenW@cbridges.org
Apply online: CommunityBridges.org/enhanced-care-management/
You can also speak with your doctor or care provider about a referral.
