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Enhanced Care Management (ECM)

What is Enhanced Care Management (ECM)?

Enhanced Care Management (ECM) is a whole-person, patient-centered case management program. ECM supports Partnership HealthPlan members with complex needs by coordinating care and connecting them with community and social resources.

ECM helps members navigate the healthcare system, provides follow-up after hospital or ER visits, and offers regular check-ins to address concerns early.

The goal is to help patients stay healthy, stable, and out of crisis by focusing on social, behavioral, and system-related needs, not just medical care.

An Enhanced Care Coordinator can assist members with finding doctors or specialists, scheduling appointments, arranging transportation, and much more!

Services offered in ECM:

  • Transportation access, including help arranging rides to medical, behavioral health, and social service appointments
  • Access to medically tailored meals to support health and nutrition needs
  • Disability application guidance, including understanding the process and completing paperwork
  • Social support, including:
    • Assistance connecting with medical specialists
    • Support accessing mental health professionals and services
    • Help with housing applications, referrals, and coordination with housing providers
  • Medical and supportive appointments, including assistance with scheduling, reminders, and follow-up for:
    • Eye exams
    • Dental care
    • Mental health services
    • Social services and other supportive programs
  • Peer support, offering encouragement, guidance, and life skills

Frequently Asked Questions

There is no cost for Enhanced Care Management (ECM) services. The cost of this service is fully funded by Partnership HealthPlan of California for eligible members.

ECM staff are not licensed clinical providers. However, they work closely with medical staff to coordinate care. All ECM care plans and services are developed with appropriate clinical oversight, and coordination occurs in collaboration with licensed medical providers to ensure care aligns with the patient’s medical needs.

ECM staff do not directly provide transportation services. However, we assist members with coordinating and planning transportation, including helping arrange rides through available community resources or health plan transportation benefits when applicable.

ECM staff do not deliver food. However, they can assist members with applying for CalFresh benefits and help coordinate referrals for medically tailored meals when appropriate, based on a member’s dietary needs and medical complexity.

ECM staff do not serve as interpreters. However, we utilize professional translation and interpretation services to support members who speak different languages, ensuring ECM services are accessible and effective for individuals with limited English proficiency.

Yes. The ECM team can help coordinate appointments by working closely with providers and their care teams. We assist with scheduling and care coordination to help ensure members receive the services and follow-up care they need.

Please contact Enhanced Care Coordinators at the Canby Family Practice Clinic at 530-708-8830. Rebecca Bales can be reached at extension 12313, and Maria Vigil can be reached at extension 12602. If you are unable to reach anyone, please leave a voicemail including your first and last name, phone number, and date of birth.

LOCATION & HOURS

Enhanced Care Management at Canby Family Practice Clinic

While housed at Canby Family Practice Clinic, the ECM program accepts and serves those eligible who are established patients of Modoc Medical Center and its associated clinics.

ELIGIBILITY

Eligibility for the Enhanced Care Management (ECM) program is based on a member’s needs.

Referrals to ECM can come from anyone, and members have the same right to apply as they do for other healthcare services. ECM is designed to support Partnership HealthPlan members who need extra help coordinating care and navigating resources.

While eligibility is determined through a screening process, ECM focuses on supporting members who fall into the following populations:

  • Individuals who use the emergency room frequently
  • Individuals with substance use concerns
  • Individuals experiencing homelessness or housing instability
  • Adults and families who are struggling and need additional support

Participation in ECM is always voluntary, and the goal is to provide support early to help prevent health and social needs from becoming crises.

Have questions?

You can reach our dedicated Enhanced Care Management program coordinators Monday through Friday from 7:30 am to 4:30 pm by calling (530) 708-8830 and dialing extension 12313 for Rebecca Bales, or extension 12602 for Maria Vigil.