Enhanced Care Management

We’re vastly improving health outcomes for high-need members by providing comprehensive care that goes beyond the hospital or doctor’s office. We’re breaking down the traditional walls of healthcare to improve the overall well being and quality of life for Medi-Cal members.

What is the Enhanced Care Management program?

Enhanced Care Management (ECM) is a free statewide Medi-Cal support service available to qualifying members with complex health and social needs as part of the DHCS’ CalAIM (Advancing and Improving Medi-Cal) program.

Black and white image of a middle aged woman in a black t-shirt and necklaces.

Transforming the complex needs of Medi-Cal members

Medi-Cal members often have multiple complex physical, behavioral, and social conditions.
Members with complex needs often need to engage multiple delivery systems to access care, such as: primary and specialty care, mental health, substance use disorder treatment, dental, vision, and longterm care services.
More than half of Medi-Cal spending is attributed to the 5 percent of members with the highest-cost needs.
ECM is a key part of Medi-Cal’s transformation to ensure that people get the care they need. It breaks down the traditional walls of health care to extend care into members’ communities. This creates a more coordinated, person centered, and equitable health system with better outcomes for everyone.

Transforming the complex needs of Medi-Cal members

Medi-Cal members often have multiple complex physical, behavioral, and social conditions. They often have to manage several, complex systems to access care for each of their problems like primary and specialty care, dental, mental health, rehabilitation and substance use disorder treatment, and more.

Members with complex needs often need to engage multiple delivery systems to access care, such as: primary and specialty care, mental health, substance use disorder treatment, dental, vision, and longterm care services.
More than half of Medi-Cal spending is attributed to the 5 percent of members with the highest-cost needs.
ECM is a key part of Medi-Cal’s transformation to ensure that people get the care they need. It breaks down the traditional walls of health care to extend care into members’ communities. This creates a more coordinated, person centered, and equitable health system with better outcomes for everyone.

Transforming the complex needs of Medi-Cal members

Medi-Cal members often have multiple complex physical, behavioral, and social conditions. They often have to manage several, complex systems to access care for each of their problems like primary and specialty care, dental, mental health, rehabilitation and substance use disorder treatment, and more.
Members with complex needs often need to engage multiple delivery systems to access care, such as: primary and specialty care, mental health, substance use disorder treatment, dental, vision, and longterm care services.
More than half of Medi-Cal spending is attributed to the 5 percent of members with the highest-cost needs.
ECM is a key part of Medi-Cal’s transformation to ensure that people get the care they need. It breaks down the traditional walls of health care to extend care into members’ communities. This creates a more coordinated, person centered, and equitable health system with better outcomes for everyone.

How does the ECM program work?

The program provides care management services directly to members from a dedicated Lead Care Manager (LCM) who coordinates all of their healthcare related needs and social services—advocating on their behalf while offering guidance, support and resources. LCMs establish high-trust and language-appropriate relationships with their members. LCMs meet members where they are, whether it’s at a coffee shop, a doctor’s appointment, at their home, shelter, or via phone or video call.

What are the services that ECM provides?

Enhanced Care Management helps Medi-Cal members in many ways:

Enhanced Care Management services

Doctors

Finding the right doctor and setting up appointments

Coordination of care

Coordinating the care from different providers

RX

Finding and arranging local food services

Food

Finding and arranging local food services

Housing

Help with housing and access social services

Dental and eye care

Connecting members dentists and eye doctors and setting up appointments

Medical supplies

Help with accessing medical equipment and medical supplies

Mental health

Connecting members to mental health services and setting up appointment

Transportation

Transportation to the doctor, pharmacy, or other medical appointments

Follow-up care

Setting up follow-up care after a hospital visit

Enhanced Care Management services

Doctors

Finding the right doctor and setting up appointments

Coordination of care

Coordinating the care from different providers

RX

Help with medications and prescription refills

Food

Finding and arranging local food services

Housing

Help with housing and access social services

Dental and eye care

Connecting members dentists and eye doctors and setting up appointments

Medical supplies

Help with accessing medical equipment and medical supplies

Mental health

Connecting members to mental health services and setting up appointment

Transportation

Transportation to the doctor, pharmacy, or other medical appointments

Follow-up care

Setting up follow-up care after a hospital visit

Enhanced Care Management services

Doctors

Finding the right doctor and setting up appointments

Coordination of care

Coordinating the care from different providers

RX

Help with medications and prescription refills

Food

Finding and arranging local food services

Housing

Help with housing and access social services

Dental and eye care

Connecting members dentists and eye doctors and setting up appointments

Medical supplies

Help with accessing medical equipment and medical supplies

Mental health

Connecting members to mental health services and setting up appointment

Transportation

Transportation to the doctor, pharmacy, or other medical appointments

Follow-up care

Setting up follow-up care after a hospital visit

For Hospitals, Health Plans and IPA’s

The California Advancing and Innovating Medi-Cal (CalAIM) initiative is a statewide commitment to:
  • Identify and manage comprehensive needs for Medi-Cal members through ‘whole person care’ approaches and social drivers of health
  • Improve quality outcomes, reduce health disparities, and transform the delivery system through value based initiatives, modernization, and payment reform
  • Make Medi-Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility.

Titanium Healthcare participates in two main CalAIM programs:
1) The Enhanced Care Management (ECM) program
The ECM program focuses on the Social Determinants Of Health (SoDOH)

2) Community Supports (CS) Program
The CS program focuses on the homelessness and housing needs for the homeless population.

How can hospitals and IPAs get involved?

When hospitals and IPAs become a partner with Titanium Healthcare they can benefit from the CalAIM initiatives in many ways, including, but not limited to:

1) Providing long-term housing options for the homeless patients

2) Addressing social issues for high utilizers like food insecurity issues

3) Reducing occupied hospital beds “ED and Inpatient” with homeless members awaiting safe discharge

4) Reducing occupied hospital beds “ED and Inpatient” with SMI members awaiting transfer

The ECM and CS programs are a long-term solution, so it is very beneficial for the members and the healthcare systems like hospitals and IPAs to partner with ECM providers like Titanium.

For more information, please contact Marc Wirtz, Chief Operating Officer at: (909) 912-4382 or email: Marc.Wirtz@tihealthcare.com

Watch our video to learn about the ECM program:

ECM means better outcomes for everyone

The program helps members engage and take charge of their own healthcare. They are able to move safely between care settings and access community and social support services that greatly improves their health and social outcomes.

  • High-need members get in-person care management where they live
  • More coordinated, whole person care
  • Reduction in frequent hospitalization
  • Breaks down the traditional walls of health care, extending beyond hospitals and health care settings into communities
Black and white image of a male nurse comforting an older female.
The ECM program changes lives. Having someone help and guide Medi-Cal members through their healthcare challenges makes a world of difference.

Who Provides Enhanced Care Management services?

Titanium Healthcare has been selected as an official provider of ECM services in California. Our program stands out for its personalized approach, our proficiency in multiple languages, our cultural understanding, and our deep commitment to helping our members and communities. Each member is paired with a dedicated, experienced Lead Care Manager who remains their constant support throughout their journey with us. Supporting our LCMs are teams of experienced nurses, housing navigators, continuity of care specialists, transitional care specialists, resource specialists, street outreach specialists, and ECM Leaders to ensure our members have access to the highest possible degree of care.

Our Care Management Leaders

Image of our Enhanced Care Management leader Barbara (Barbie) Manbodh

Barbara (Barbie) Manbodh

Director of ECM
Central & Northern
California

Image of our Enhanced Care Management leader Makesha Satterwhite

Cynthia Perez

Director of ECM
Southern California

Image of our Community Support leader Rene Munoz Guillen

Patricia (Patty) Villasenor

Director of Outreach & Engagement

Image of our Enhanced Care Management leader Jacob Dillon

Jacob Dillon

ECM Regional Manager
NorCal

Image of our Enhanced Care Management leader Eva Avalos

Eva Avalos

ECM Regional Manager
SoCal/High/Low Desert

Image of our Enhanced Care Management leader Fernando Suarez

Fernando Suarez

Outreach Manager

Image of our Enhanced Care Management leader Jacob Dillon

Christina Valderrama

ECM Regional Manager
CenCal

Image of our Enhanced Care Management leader Barbara (Barbie) Manbodh

Barbara (Barbie) Manbodh

Director of ECM
Central & Northern
California

Image of our Enhanced Care Management leader Makesha Satterwhite

Cynthia Perez

Director of ECM
Southern California

Image of our Community Support leader Rene Munoz Guillen

Patricia (Patty) Villasenor

Director of Outreach & Engagement

Image of our Enhanced Care Management leader Jacob Dillon

Jacob Dillon

ECM Regional Manager
NorCal

Image of our Enhanced Care Management leader Eva Avalos

Eva Avalos

ECM Regional Manager
SoCal/High/Low Desert

Image of our Enhanced Care Management leader Fernando Suarez

Fernando Suarez

Outreach Manager

Image of our Enhanced Care Management leader Jacob Dillon

Christina Valderrama

ECM Regional Manager
CenCal

Success Stories

Black and white image of Maria.

Transplant Hope

Maria is 53-years old and has arthritis, hypertension, diabetes, and chronic kidney disease. She attends dialysis treatment at least three times a week and has been managing her kidney disease for over five years. During our first in-person encounter, we talked about a kidney transplant.

Collaborating with the social worker who provides services at Maria’s dialysis center, we were able to obtain an authorization from Maria’s health plan for her to be evaluated for a kidney transplant. Maria now has the appointment for evaluation scheduled. In our most recent meeting, she expressed joy as she shared that she is now “hopeful” about her future.

Black and white image of Lupita

Transportation Sorted

Lupita, had an aneurysm and had undergone craniotomy surgery. She lives in a remote area far from the city and struggled to get to her appointments. Lupita’s roommate used to give her rides to her medical appointments, but is now unable. Lupita was anxious about missing her medical appointments as she couldn’t find a reliable alternative.

We helped arrange transportation services for her medical appointments and provided her with the contact number to call whenever she needed assistance. We also assured her that she can call us for help in setting up transportation whenever she needs to which she expressed deep gratitude and relief.

Black and white image of Bill.

Mental health, the big picture

Bill, 35 years old, is one of our CalOptima patients and has been homeless and living in his car for about six years. Along with pancreatitis and some other medical issues (swollen legs, ankles, tinnitus), Bill also has an alcohol addiction. He had no doctor or care team before Titanium became involved in his care. We struggled to get Bill to talk about his alcohol problems, but eventually, we were able to get him into a sobriety and rehab center get him off the streets, and get him the medical and mental health care he needed. When we met with Bill last, he was doing well, is staying with the program, and is getting his life back on track.

*Members’ names and photos have been changed to protect their privacy.

Black and white image of Maria.

Transplant Hope

Maria is 53-years old and has arthritis, hypertension, diabetes, and chronic kidney disease. She attends dialysis treatment at least three times a week and has been managing her kidney disease for over five years. During our first in-person encounter, we talked about a kidney transplant.

Collaborating with the social worker who provides services at Maria’s dialysis center, we were able to obtain an authorization from Maria’s health plan for her to be evaluated for a kidney transplant. Maria now has the appointment for evaluation scheduled. In our most recent meeting, she expressed joy as she shared that she is now “hopeful” about her future.

Transportation Sorted

Lupita, had an aneurysm and had undergone craniotomy surgery. She lives in a remote area far from the city and struggled to get to her appointments. Lupita’s roommate used to give her rides to her medical appointments, but is now unable. Lupita was anxious about missing her medical appointments as she couldn’t find a reliable alternative.

We helped arrange transportation services for her medical appointments and provided her with the contact number to call whenever she needed assistance. We also assured her that she can call us for help in setting up transportation whenever she needs to which she expressed deep gratitude and relief.

Black and white image of Bill.

Mental health, the big picture

Bill, 35 years old, is one of our CalOptima patients and has been homeless and living in his car for about six years. Along with pancreatitis and some other medical issues (swollen legs, ankles, tinnitus), Bill also has an alcohol addiction. He had no doctor or care team before Titanium became involved in his care. We struggled to get Bill to talk about his alcohol problems, but eventually, we were able to get him into a sobriety and rehab center get him off the streets, and get him the medical and mental health care he needed. When we met with Bill last, he was doing well, is staying with the program, and is getting his life back on track.

*Members’ names and photos have been changed to protect their privacy.

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Titanium Healthcare Inc./Sterling Hospitalist Medical Group.
12566 Valley View Street Garden Grove, CA 92845

© Titanium Healthcare® Inc. | All Rights Reserved.

© Titanium Healthcare® Inc. | All Rights Reserved.