When navigating a serious health condition is hard enough, Enhanced Care Management through Pacific Health Group makes sure no one has to do it alone.

Every day, thousands of people face a difficult reality: managing a chronic disease, a mental health condition, or a substance use disorder while also dealing with unstable housing, food insecurity, or a lack of reliable transportation. Many times, a routine doctor’s appointment is just one small piece of a much larger puzzle. The traditional healthcare system, designed around single visits and isolated treatments, often falls short of addressing the full scope of their needs.

That’s exactly where Enhanced Care Management (ECM) comes in — and why ECM providers like Pacific Health Group are making a real difference in communities across California.

What is Enhanced Care Management?

Enhanced Care Management is a statewide Medi-Cal managed care benefit established by the California Department of Health Care Services (DHCS) under the CalAIM initiative. It is designed to provide a whole-person approach to care — one that addresses both the clinical and non-clinical circumstances of Medi-Cal members with the most complex needs.

Unlike standard care management, ECM goes beyond the walls of a doctor’s office or emergency department. It connects eligible members with a dedicated Lead Care Manager (LCM) — a trained provider who coordinates every aspect of that person’s health and social wellbeing. This includes physical health, mental health, oral health, medication management, and access to vital community resources.

ECM services are provided primarily through in-person, community-based interaction — meeting patients where they live, work, and seek care. The goal is simple but powerful: improve health outcomes and quality of life for those who need the most support.

It is important to note that ECM is distinct from Medicare. ECM is specifically a Medi-Cal managed care benefit for low-income Californians enrolled in a Medi-Cal managed care plan. If you are unsure about your eligibility, your Medi-Cal health plan or a trusted provider can help clarify it.

Who qualifies for Enhanced Care Management?

ECM is available to Medi-Cal members who fall into one or more defined Populations of Focus, including:

• Adults and families experiencing homelessness or housing instability
• High utilizers of the emergency department — individuals who have had multiple ER visits or hospitalizations in the past 6–12 months
• Adults with serious santé mentale conditions and/or substance use disorder (SUD) needs
• Adults at risk of long-term care institutionalization or nursing home placement
• Nursing home residents who wish to transition back into the community
• Children and youth involved in foster care or the child welfare system
• Children and youth enrolled in California Children’s Services (CCS) or the CCS Whole Child Model with complex additional needs
• Individuals re-entering the community from prison or other correctional facilities
• Patients managing chronic conditions such as asthma, diabetes, or those recovering from a serious injury
• Pregnant and postpartum individuals, with a focus on those from Black, Indigenous, and other communities of color who face a higher risk of maternal health complications, inequitable access to care, and systemic barriers that can impact birth outcomes — this population is a priority under ECM’s commitment to birth equity

If you know someone in your community who fits one or more of these categories and is enrolled in a Medi-Cal managed care plan, they may be eligible to receive ECM services — at no cost to them.

How ECM addresses complex medical and social needs

What makes ECM distinct from traditional care coordination is its recognition that health is shaped by far more than medical diagnoses. Social determinants of health — including housing, food access, income, language barriers, and transportation — directly impact a patient’s ability to get well and stay well.

Through ECM, members receive support across several core service areas:

1. Comprehensive Care Planning

 A Lead Care Manager works collaboratively with the patient, their physicians, specialists, and support network to develop a personalized care plan. Accessibility is a central priority — care plans are culturally responsive and available in the member’s preferred language, ensuring that no one is left behind due to communication barriers.

2. Care Coordination and Navigation 

ECM providers coordinate appointments, manage specialist referrals, reconcile medication, and ensure that all treating providers are communicating effectively. For a patient managing multiple chronic conditions — from asthma to a complex injury — this level of coordination can be life-changing.

3. Community Supports and Social Services Linkage

 ECM works hand-in-hand with Community Supports (CS) — a companion Medi-Cal benefit that provides services such as housing transition assistance, medically tailored meals, and asthma remediation. Together, ECM and Community Supports bridge the gap between health care and the broader social determinants of health, addressing root-cause barriers that undermine long-term wellness.

4. Transitional Care 

For patients being discharged from a hospital, nursing home, or correctional facility like prison, ECM provides crucial support during that vulnerable transition period — helping with discharge planning, follow-up appointments, medication reconciliation, and transportation to ensure continuity of care.

5. Behavioral Health Integration 

ECM integrates behavioral health, which includes mental health and substance use disorder support, directly into the care management process, ensuring that emotional and psychological needs are treated alongside physical health — not in isolation from it.

Pacific Health Group’s approach to Enhanced Care Management

Pacific Health Group is a trusted CalAIM ECM provider serving Medi-Cal members across California. Grounded in the mission to empower life, Pacific Health Group delivers comprehensive, person-centered care management that combines clinical expertise with genuine human compassion.

Their ECM services are built around several key pillars:

Dedicated Lead Care Managers who build trust, communicate in the patient’s preferred language, and serve as the primary point of contact for members and their families

Transportation coordination to ensure patients can reliably access the health care they need

Social services and Community Supports spanning housing assistance, food access, financial guidance, and more

Behavioral health services that address mental wellness, substance use, and emotional well-being in an integrated, destigmatized way

Pacific Health Group’s approach prioritizes accessibility, language inclusivity, and community trust. Their providers don’t just coordinate care — they walk alongside patients through their entire health journey.

How to make a referral to Pacific Health Group

Health care providers, social workers, teachers, faith leaders, and community members all play a critical role in connecting eligible individuals to ECM. Many patients who would benefit most from Enhanced Care Management don’t know it exists.

Making a referral is straightforward:

• Providers can submit a completed referral form through the member’s Medi-Cal managed care plan portal or directly to Pacific Health Group
• To confirm Pacific Health Group is a contracted ECM provider in your area, check your plan’s provider directory
• Individuals can self-refer by contacting their Medi-Cal health plan or calling Pacific Health Group directly
• Members who receive services through CCS, foster care, or other state programs may have additional pathways to qualify — a provider or care manager can help navigate that information
• The most efficient way to enroll a member in Pacific Health Group’s Enhanced Care Management is by calling our phone number directly at (888) 341-4449.

The earlier a patient is connected to ECM, the sooner they can begin receiving the coordinated, whole-person support that can genuinely transform their health and quality of life.

Take the next step

If you or someone you know could benefit from Enhanced Care Management, Pacific Health Group is here to help. If you know someone who could benefit from our services but is uninsured, we can also help them apply for Medi-Cal to make sure they have access to the services they need!

• Refer someone or learn about eligibility: Call (888) 341-4449
• Visit our website: mypacifichealth.com

Pacific Health Group serves Medi-Cal members and their communities across California. Our team is available Monday through Friday to answer questions, verify eligibility, complete a referral form, and guide the process every step of the way.

Because every patient deserves care that sees the whole person — not just the diagnosis.