Enhanced Care Management (ECM) is more than just healthcare coordination; it’s a partnership. Our Care Coordinators provide intensive, hands-on support that addresses every aspect of your health and wellbeing.

We don’t just make referrals and wish you luck. We walk alongside you, remove barriers, coordinate with all your providers, connect you to community resources, and stay with you until your goals are achieved.

ECM is completely free for eligible Medi-Cal members. There are no co-pays, no fees, no charges of any kind.

What Makes ECM Different

Traditional Care Management:

• Short-term support (weeks to a few months)
• Focus on medical needs only
• Rotating case workers
• Reactive (responds to crises)
• Time-limited interventions

Enhanced Care Management (ECM):

• Long-term support (as long as needed)
• Whole-person approach (medical, behavioral, social)
• Dedicated Care Coordinator (stays with you)
• Proactive (prevents problems before they start)
• Comprehensive and continuous

What It Is

We reach out to connect with you, build trust, and understand how we can best support you.

What This Looks Like

• Initial phone call or home visit to introduce ourselves
• Explaining ECM services in clear, simple language
• Listening to your concerns, challenges, and goals
• Building a relationship based on trust and respect
• Meeting you where you are—literally and figuratively
• Persistent, gentle outreach if you need time to build trust

Your Care Coordinator Will:

• Introduce themselves and explain their role
• Ask about your health, living situation, and current challenges
• Explain what ECM can do for you
• Answer all your questions
• Set up a schedule for regular communication that works for you

We understand that trusting someone new takes time. We’re patient, consistent, and here when you’re ready.

What It Is

A thorough evaluation of your health, social needs, strengths, and goals—followed by a personalized plan created WITH you, not FOR you.

What This Looks Like

We assess:

• Your medical conditions and treatment needs
• Behavioral health and substance use support needs
• Housing stability and safety
• Food security and nutrition
• Transportation access
• Financial resources and benefits
• Social support and family connections
• Cultural preferences and language needs
• Your strengths, capabilities, and resources
• What’s most important to YOU

Your Personalized Care Plan Includes:

• Your health and wellness goals (in your own words)
• Specific action steps with clear timelines
• Resources and services you need
• Who is responsible for each step (you, your Care Coordinator, providers)
• How we’ll measure progress
• Plan for emergencies or setbacks

This is YOUR plan. You decide what goals matter most, and we build the roadmap together.

What It Is

We coordinate ALL aspects of your care—medical, behavioral, and social—ensuring everyone involved is working together toward your goals.

What This Looks Like

Medical Coordination:

• Scheduling appointments with primary care, specialists, and labs
• Following up on test results and treatment recommendations
• Coordinating between multiple doctors and providers
• Ensuring medication lists are accurate and up-to-date
• Arranging medical equipment and supplies
• Hospital discharge planning and follow-up

Behavioral Health Coordination:

• Connecting you to mental health therapy and psychiatry
• Coordinating substance use treatment services
• Linking medical and behavioral health providers
• Supporting medication-assisted treatment (MAT)
• Crisis planning and safety planning
• Peer support and support group connections

Social Service Coordination:

• Connecting to housing resources and rental assistance
• Enrolling in food assistance programs (CalFresh, food banks)
• Arranging non-emergency medical transportation
• Applying for financial benefits (SSI/SSDI, General Relief)
• Accessing legal aid and advocacy services
• Coordinating with child welfare, probation, or other agencies

Community Resource Coordination:

• Connecting to clothing, diapers, and household essentials
• Home modification and accessibility services
• Asthma remediation and environmental health
• Employment and education programs
• Faith-based and cultural community supports

Your Care Coordinator Will:

• Be the central point of contact for all your providers
• Communicate between your doctors, therapists, and social workers
• Track appointments and follow-ups
• Make sure nothing falls through the cracks
• Advocate for your needs with all systems
• Solve problems before they become crises

You’ll never have to repeat your story or navigate confusing systems alone.

What It Is

Education, coaching, and support to help you manage your health conditions and make informed decisions about your care.

What This Looks Like

• Teaching you about your diagnoses and treatment options
• Helping you understand medications and how to take them correctly
• Coaching on chronic disease self-management (diabetes, asthma, heart disease)
• Supporting healthy lifestyle changes (nutrition, physical activity, sleep)
• Preventive care education (screenings, vaccinations, dental care)
• Guidance on recognizing warning signs and when to seek help
• Building your confidence to communicate with healthcare providers
• Connecting you to health education classes and programs

Your Care Coordinator Will:

• Explain medical information in plain language
• Help you prepare questions for doctor appointments
• Teach you how to track symptoms and medications
• Connect you to diabetes education, asthma management programs, etc.
• Support you in making health-related decisions
• Celebrate your progress and help you overcome setbacks

Knowledge is power. We make sure you understand your health and feel confident managing it.

What It Is

Intensive support during critical transitions—from hospital to home, between care settings, or after major life changes.

What This Looks Like

Hospital to Home:

• Meeting you at the hospital before discharge
• Ensuring you understand discharge instructions
• Scheduling follow-up appointments before you leave
• Arranging transportation home and to follow-ups
• Coordinating home health services if needed
• Following up within 24-48 hours after discharge
• Medication reconciliation and pickup assistance

Other Transitions:

• Nursing facility to community
• Residential treatment to home
• Incarceration to community re-entry
• Emergency shelter to permanent housing
• Foster care placement changes
• Changing health plans or providers

Your Care Coordinator Will:

• Start planning before the transition happens
• Be present during critical transition moments
• Make sure prescriptions are filled and transportation is arranged
• Check in frequently during the adjustment period
• Address problems immediately before they lead to readmission
• Ensure continuity of care with no gaps in service

Transitions are vulnerable times. We’re there to make sure you don’t fall through the cracks.

What It Is

Involving your family, caregivers, and support system in your care—with your permission—and providing them with resources and support too.

What This Looks Like

• Including family members in care planning (if you want)
• Educating family about your health conditions
• Supporting caregivers who are helping you
• Connecting families to respite care and support services
• Mediating between you and family when needed
• Providing resources for family members
• Recognizing cultural values around family involvement
• Supporting parent/child coordination for pediatric members

Your Care Coordinator Will:

• Ask who you want involved in your care
• Respect your privacy and autonomy
• Include family members in meetings and planning
• Provide education and resources to your support system
• Connect caregivers to their own support services
• Help your family understand how to best support you

Your support system is part of your strength. We help them help you—while always respecting your choices.

What It Is

Connecting you to the wide range of community resources, social services, and supports that address your basic needs and improve quality of life.

What This Looks Like

CalAIM Community Supports (Examples):

• Housing navigation and tenancy sustaining services
• Short-term housing assistance and respite
• Medically tailored meals and nutrition supports
• Sobering centers and recuperative care
• Respite services for caregivers
• Environmental accessibility adaptations (ramps, grab bars)
• Personal care and homemaker services
• Day rehabilitation and community integration

Additional Community Resources:

• Food banks and meal programs
• Clothing closets and diaper banks
• Utility assistance programs
• Legal aid and tenant rights
• Employment and job training
• Education and literacy programs
• Immigration services
• Transportation programs
• Cultural and faith-based organizations

Your Care Coordinator Will:

• Identify all available resources that match your needs
• Help you apply for programs and services
• Make warm handoffs to community partners
• Follow up to ensure you received the services
• Advocate if you encounter barriers
• Connect you to both formal services and informal supports

We know the community inside and out. If a resource exists, we’ll help you access it.

In addition to the seven core ECM services, California’s CalAIM initiative offers Community Supports (also called Enhanced Care Management Community Supports or “In Lieu of Services”). These are non-traditional services that address social determinants of health.

Community Supports are provided at no cost to eligible ECM members.

Available Community Supports

• Housing Transition Navigation Services Help finding and securing housing, including application assistance, housing search, and move-in support
• Housing Deposits Assistance with security deposits and one-time move-in costs
• Housing Tenancy and Sustaining Services Ongoing support to help you maintain stable housing, including landlord mediation and life skills coaching
• ️Medically Tailored Meals Prepared meals designed for your specific health conditions (diabetes, heart disease, renal diet, etc.)
• Medically Tailored Groceries Food packages tailored to your dietary needs and health conditions
• ️Sobering Centers Short-term residential services for individuals to safely recover from intoxication
• Recuperative Care (Medical Respite) Short-term residential care for members who are too ill to recover on the streets but don’t need hospital-level care
• Environmental Accessibility Adaptations Home modifications like ramps, grab bars, stair lifts, and other accessibility improvements
• Personal Care and Homemaker Services Assistance with activities of daily living, housekeeping, meal preparation, and personal care
• Day Habilitation Programs Community-based programming that assists with acquiring, retaining, and improving skills
• Respite Services Temporary relief for family caregivers
• Non-Medical Transportation Transportation to social services, community resources, and other non-medical needs
• Nursing Facility Transition/Diversion Support transitioning from nursing facilities to community living
• Asthma Remediation Home environmental assessments and modifications to reduce asthma triggers
• Remote Patient Monitoring Technology and support for monitoring health conditions from home

How to Access Community Supports

Your Care Coordinator will:

1. Assess your needs and determine which Community Supports you qualify for
2. Submit authorization requests to your health plan
3. Connect you with approved providers
4. Monitor the services to ensure they’re meeting your needs
5. Adjust services as your situation changes

Not all members will need all Community Supports. Services are individualized based on your care plan.

One of the most important aspects of ECM is having a dedicated Care Coordinator who stays with you throughout your enrollment. Here’s what that ongoing relationship looks like:

Regular Check-Ins

Minimum Contact:

• At least biweekly (every two weeks) check-ins
• More frequent contact when you’re in crisis or transition
• Flexible scheduling based on your availability

Contact Methods:

• Phone calls
• Text messages
• In-person visits
• Home visits when appropriate
• Video calls if preferred
• Email

Responsive Communication

• Your Care Coordinator responds to your calls and texts promptly
• You have a direct line to reach your Care Coordinator
• Same-day response for urgent needs
• After-hours crisis resources provided

Relationship Continuity

• Same Care Coordinator throughout your enrollment (no rotating staff)
• Your Care Coordinator knows your history, goals, and preferences
• No need to repeat your story with every interaction
• Trust builds over time through consistent support

You’re not just a case number. You’re a person with goals, strengths, and challenges—and your Care Coordinator knows that.

Unlike many programs with strict time limits, Enhanced Care Management provides support for as long as you need it and continue to meet eligibility criteria.

There is no predetermined end date. Some members work with us for a few months; others stay enrolled for years. The length of support depends entirely on your needs and goals.

Ongoing Enrollment

You remain enrolled in ECM as long as:

• You continue to meet populations of focus eligibility criteria
• You remain enrolled in Medi-Cal
• You remain with a participating health plan (Kaiser, Molina, or IEHP)
• You choose to continue receiving services

What Happens When ECM Ends?

When you’re ready to graduate from ECM—or if you no longer meet eligibility criteria—your Care Coordinator will:

• Help you transition to ongoing supports in the community
• Connect you to less intensive care management if needed
• Ensure all your providers have updated information
• Provide resources for continued success
• Offer follow-up support as you transition
• Celebrate your progress and achievements

Our goal is to support you until you feel confident and stable—not to rush you out when arbitrary time limits expire.

Green Tree Wellness is committed to providing culturally sensitive, linguistically appropriate care.

Language Services

Professional interpreter services available in all languages at no cost

• Many of our Care Coordinators are bilingual
• All written materials can be translated
• Interpretation provided for all appointments and meetings
• Your right to language assistance is protected by law

Se habla español. We speak your language.

Cultural Sensitivity

Our Care Coordinators receive ongoing training in:

• Cultural humility and awareness
• Trauma-informed care
• LGBTQ+ affirming practices
• Working with diverse communities
• Respecting religious and cultural beliefs
• Understanding structural barriers and discrimination

We respect your identity, beliefs, values, and experiences. We adapt our approach to honor what’s important to you.

As an ECM member, you have important rights:

• Right to participate in your care plan – You decide what goals matter most
• Right to refuse services – ECM is voluntary; you can opt out at any time
• Right to privacy – Your information is protected under HIPAA
• Right to respectful treatment – Free from discrimination and judgment
• Right to language assistance – Services in your preferred language
• Right to file a grievance – If you’re unhappy with services
• Right to change Care Coordinators – If the relationship isn’t working

You are in control. We’re here to support YOUR goals in the way that works best for YOU.

To set clear expectations, here’s what ECM does NOT include:

• ECM is not emergency services – Call 911 for medical emergencies
• ECM is not 24/7 crisis intervention – We provide crisis resources and support during business hours
• ECM is not clinical care – We coordinate care but don’t replace your doctors or therapists
• ECM is not financial assistance – We connect you to programs but don’t provide direct financial support
• ECM is not housing placement – We help navigate housing resources but don’t own or operate housing
• ECM is not legal representation – We connect to legal aid but don’t provide legal services

We’re care coordinators and advocates—we help you access the services and supports you need but work within our scope of practice.