Enhanced Care Management (ECM) for CalAIM Members
Comprehensive care coordination for members with complex needs
Enhanced Care Management provides intensive coordination for CalAIM members facing multiple challenges across Vallejo, Fairfield, Vacaville, Santa Rosa and surrounding communities. Integrated with our housing programs, ECM addresses the medical, behavioral, and social factors that impact health outcomes.
Who Benefits from ECM
ECM serves CalAIM members throughout Vallejo, Fairfield, Vacaville, and Santa Rosa experiencing:
Homelessness or housing instability with health complications
Frequent hospital or ED utilization (high utilizers)
Serious mental illness requiring coordinated support
Substance use disorders with co-occurring conditions
Complex chronic conditions requiring multiple providers
Transitions of care between settings or systems
Core ECM Services
We coordinate services, reduce discharge delays, and help CalAIM members achieve stability through a whole-person approach.
How ECM Works Within Our Programs
Enhanced care management and housing work together to address your whole situation, not just isolated problems.
ECM can be integrated with any of our housing services:
- Recuperative Care + ECM: Medical recovery with intensive coordination
- STPH + ECM: Post-hospital housing with comprehensive support
- Transitional Housing + ECM: Extended stability with wraparound services
- Sober Living + ECM: Recovery housing with coordinated care
- Day Habilitation + ECM: Intensive daytime programming with coordinated care planning
Healthcare Coordination Hub
Enhanced care management in Solano County and Sonoma County takes a whole-person approach, addressing not just your medical needs but also behavioral health, housing stability, and social challenges. Our ECM care team becomes an advocate, helping to navigate systems that can feel complicated and overwhelming.
Quick Partner Information
Coverage
CalAIM Enhanced Care Management for eligible members
Service Area
Solano & Sonoma Counties
Integrated With
All Hammock Homes housing programs
Referral Response
Usually same day
Why Integrated ECM + Housing Works
Research shows that addressing both housing and healthcare together dramatically improves outcomes. When ECM is delivered in stable housing:
Emergency department visits decrease
Hospital readmissions drop
Medication adherence improves
Primary care engagement increases
Our integrated approach ensures members don’t have to choose between housing and healthcare support—they receive both in one coordinated program.
Additional Resources
Ready to Refer?
For hospitals, case managers, and community clinicians – use one of the methods below to begin the referral process.
Frequently Asked Questions
Yes. ECM integrates with all Hammock Homes housing programs to support both health and housing stability.
ECM provides whole care coordination, including active communication between all providers, comprehensive care planning, and addressing social determinants of health beyond just housing.
Partnership HealthPlan, hospitals, health clinics, behavioral health providers, and other community organizations can refer members who qualify for both ECM and housing services.
ECM duration is based on individual needs and continues as long as the member meets eligibility criteria and benefits from the intensive coordination. Assessed every 6 months.
Yes, ECM includes transportation coordination and assistance for medical appointments and essential services.