Enhanced Care Management
Supportive Housing & Services
a CalAIM provider
Enhanced Care Management in Solano & Sonoma Counties
Your personal healthcare navigator—coordinating all your care and connecting you to services you need in Northern California
When life feels overwhelming and you’re managing complex health needs, housing challenges, or multiple appointments, Enhanced Care Management (ECM) provides the coordination and support to pull it all together. Hammock Homes offers CalAIM ECM services to help you navigate the healthcare system and access the resources you need.
What is Enhanced Care Management?
Enhanced Care Management is intensive care coordination for Medi-Cal members with complex needs. Think of it as having a dedicated care team that works exclusively for you—coordinating your medical appointments, connecting you to housing and social services, and ensuring nothing falls through the cracks.
Who Qualifies for Enhanced Care Management
ECM is designed for Medi-Cal members with complex health and social needs. You may qualify if you are:
Unhoused or at Risk of Losing Housing
Currently unhoused or experiencing housing Housing instability impacts your ability to manage health conditions and access care consistently.
Frequent Emergency Department User
Multiple ER visits or hospitalizations indicate you need better care coordination and access to primary care.
Living with Serious Mental Health or Substance Use Conditions
Complex behavioral health needs require integrated coordination across multiple providers and services.
Transitioning from Incarceration
Justice-involved individuals returning to the community need support reconnecting to healthcare and services.
Managing Complex Chronic Health Conditions
Multiple health conditions requiring coordination across specialists and treatment plans.
Pregnant or Postpartum with Risk Factors
High-risk pregnancies or postpartum periods requiring additional support and monitoring.
History of Foster Care or Child Welfare Involvement
Young adults with child welfare history often need intensive support navigating systems independently.
Your Enhanced Care Management Team
Dedicated Lead Care Manager
Your main point of contact who knows your situation, advocates for your needs, and coordinates all your services.
Care Coordination Across All Providers
We communicate with your doctors, specialists, therapists, and other providers to ensure everyone is working together.
Connection to Specialists and Services
Help accessing the right specialists, treatment programs, and community resources for your specific needs.
Healthcare System Navigation
Guidance understanding insurance, making appointments, following up on referrals, and accessing benefits.
Personal Advocacy
Someone in your corner who speaks up for your needs and helps remove barriers to care.
CalAIM ECM Services We Provide
Comprehensive Needs Assessment
In-depth evaluation of your medical, behavioral, social, and housing needs to understand the full picture.
Personalized Care Plan Development
A detailed plan tailored to your unique situation, goals, and priorities.
Appointment Scheduling and Reminders
Help making appointments and reminders so you don't miss important care.
Transportation Coordination
Arranging rides to medical appointments, treatment programs, and essential services.
Medication Management Support
Help understanding medications, picking up prescriptions, and managing side effects.
Connection to Housing Services
Linking you to our sober living, recuperative care, or post-hospitalization housing when appropriate.
Benefits Enrollment Assistance
Support applying for SSI, SSDI, CalFresh, and other benefits you're eligible for.
Health Education and Self-Management
Teaching you skills to manage your conditions and make informed healthcare decisions.
Crisis Support and Safety Planning
Help during emergencies and planning ahead for situations that might trigger crisis.
Transition Support
Coordinated care during critical transitions—hospital to home, treatment to community, or jail to community.
Provider Coordination
Regular communication with all your healthcare providers to ensure cohesive, aligned care.
How ECM Integrates with Housing Services
Enhanced care management and housing work together to address your whole situation, not just isolated problems.
ECM Can Connect You to Housing
If you need housing, your care manager can help you access our sober living, recuperative care, or short-term post-hospitalization housing services.
Housing Residents Receive ECM Support
If you're living in one of our homes, ECM coordinates your medical care, behavioral health services, and other needs.
Working with Your Existing ECM Provider
Already have an ECM provider? We coordinate with them to ensure seamless support for your housing needs.
Providing Direct ECM Services
We can serve as your ECM provider, offering intensive case management that includes housing coordination.
Addressing Social Determinants of Health
ECM recognizes that stable housing, food security, and social support are as important to your health as medical care.
Which Service Is Right for You?
As your care coordinator, we help you determine which Hammock Homes services fit your
needs. Here's how to think about your options:
Many people benefit from multiple services at once like living in recuperative care while receiving ECM coordination, or participating in day habilitation while in transitional housing. We’ll help you figure out the best combination for your situation.
Length of Enhanced Care Management Services
How to Enroll in ECM Services
Contact Partnership HealthPlan Member Services
Call the number on your Medi-Cal card and ask about Enhanced Care Management eligibility.
Ask Your Doctor for a Referral
Your primary care provider, specialist, or behavioral health provider can refer you to ECM.
Call Hammock Homes Directly
Reach out to us—we can help facilitate your enrollment and determine if you qualify.
Hospital Discharge Planning
Discharge planners can connect you to ECM during hospitalization or at discharge.
County Social Services Referral
County social workers and case managers can refer eligible individuals to ECM.
Outcomes That Matter
Enhanced care management produces meaningful improvements for members with complex needs:
Why Choose Hammock Homes for Care Coordination
Integrated Housing and Healthcare Model
We understand that housing and health are inseparable—our ECM services reflect this reality.
CalAIM Community Support Provider
We offer the full range of CalAIM services, from housing to care coordination, creating seamless support.
Partnership HealthPlan Contracted Provider
Our established relationship ensures smooth enrollment and coordinated care for members.
Serving Solano and Sonoma Counties
Local presence and knowledge of community resources in the areas we serve.
Trauma-Informed, Person-Centered Approach
We recognize that complex needs often stem from trauma and approach care with empathy and respect.
Experience with Complex Populations
Our team understands the unique challenges faced by individuals managing multiple health, behavioral health, and social needs.
Get Started with Enhanced Care Management
Whether you're struggling to manage multiple health conditions, need help navigating the healthcare system, or require intensive support coordinating housing and medical care, ECM
can help.
For Individuals:
Reach out to learn about eligibility and how Enhanced Care Management can support your health and stability goals.
For Healthcare Professionals:
Contact us to discuss patient needs and coordinate ECM referrals for eligible Partnership HealthPlan members.
You don’t have to navigate complex health and social systems alone. Our Enhanced Care
Management services provide the coordination, advocacy, and support you need to achieve
better health and stability.