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For Californians with complex needs

Enhanced Care Management in California

When health care, behavioral health, and daily-life needs overlap, one clear point of coordination can make the next step easier to find.

Start an ECM ReferralHow ECM works
A care professional coordinating next steps with a patient

Care that connects the dots

Support should not depend on how well someone can navigate the system alone.

Enhanced Care Management, often called ECM, is a whole-person approach to care coordination. It is designed for people whose health needs are shaped by several moving pieces, such as chronic conditions, behavioral health needs, frequent care transitions, unstable housing, transportation barriers, or difficulty keeping up with appointments and medications.

The purpose is practical: help the right people communicate, help the person understand what happens next, and make a care plan that works in real life. It does not replace a person’s doctor, specialist, health plan, or community support. It helps those relationships work together with less friction.

A steadier path forward

What coordinated support can look like

Every person’s needs are different. The work begins by understanding what is getting in the way of care and identifying the most useful next step.

1

Start with the whole picture

A care coordinator learns about current health needs, recent changes, existing providers, and the practical barriers that make care harder to manage.

2

Build a connected plan

The plan can bring together medical, behavioral, and community supports, with priorities that feel realistic for the person and their family.

3

Stay connected through change

Support can help during transitions, follow-up needs, and changing circumstances, so important details are less likely to fall through the cracks.

When it may help

For people carrying more than one kind of need

Health care becomes difficult to manage when a person is seeing multiple providers, leaving the hospital, coping with a new diagnosis, or trying to keep appointments while handling work, caregiving, housing, transportation, or financial pressure. It can also be hard when the person is not sure which professional to call first.

ECM can create a clearer path for people with complex medical, behavioral, and social needs. That may include coordinating with primary care and specialists, preparing for a safer transition home after an emergency department or hospital visit, reviewing medication follow-up needs, or connecting a person with community resources when they are available and appropriate.

It is not about adding another confusing program. It is about making existing care easier to use. A care coordinator can help surface questions, keep the team informed, and focus on the practical actions that matter most right now.

For referring partners

A referral begins with a useful conversation.

Primary care teams, hospital staff, behavioral health providers, community organizations, caregivers, and others may see first when someone could benefit from more connected support. The best referral does not need to contain every answer. It simply explains the basic concern and gives the care coordination team a place to start.

Harmony Wellness & Health follows up to understand the person’s needs and the most appropriate next step. Eligibility and enrollment are determined through the appropriate care process and health plan. Please do not include urgent concerns or detailed medical records in the referral form.

Start an ECM Referral
Clinician discussing a personalized care plan
Patient speaking with a clinician in a video visit

Clear roles, better handoffs

What ECM can do, and what it does not replace

ECM is most useful when it adds clarity to a busy care picture. A coordinator can help a person prepare questions for a visit, understand which follow-up is due, and keep the right people aware of an important change. When someone leaves the hospital, for example, the next few days can involve prescriptions, primary care, specialty visits, transportation, and questions from family. Coordinated support can help make that transition easier to follow.

ECM does not take the place of emergency care. For chest pain, trouble breathing, signs of stroke, or another emergency, call 911. It also does not replace the clinical judgment of a physician, therapist, pharmacist, or health plan. Instead, it helps the person and their existing care team stay connected around the practical work of a plan.

That distinction matters. Good coordination should make care feel more human, not create another layer of instructions. The aim is a plan that reflects the person’s priorities, respects their choices, and turns a complicated set of needs into a few understandable next actions.

After you reach out

What to expect next

01

Share the basics

Use the secure referral form to describe the need at a high level. Avoid urgent details or records.

02

We follow up

The care coordination team connects to learn more and discuss the person’s circumstances.

03

Find the right path

The next step may include checking eligibility, coordinating with the health plan, or connecting to an appropriate service.

Questions, answered

Enhanced Care Management FAQs

Who may benefit from Enhanced Care Management?

Enhanced Care Management may be helpful for people whose health needs involve more than one provider, service, or life challenge. It can be especially valuable when appointments, medications, care transitions, and daily responsibilities are hard to coordinate at the same time. Someone does not need to solve every challenge before reaching out. The referral conversation can help identify which need is most urgent and whether coordinated support is the right fit. Eligibility and enrollment are determined through the appropriate health plan and care process. A referral is a useful place to begin the conversation.

Can a provider, family member, or community partner make a referral?

Yes. A referral can start with someone who sees that a person may need more coordinated support. Primary care teams, hospitals, behavioral health providers, community organizations, and caregivers may all notice when a more connected approach could help. The person’s privacy and choices remain important throughout the process. Share only the basic information needed to begin the conversation, and the team can follow up about the appropriate next step.

Is Enhanced Care Management the same as primary care?

No. Primary care and Enhanced Care Management have different roles. Primary care provides clinical evaluation and treatment, while care coordination helps make the broader plan easier to follow. Care coordination can help connect primary care, specialty care, behavioral health, hospitals, pharmacies, and community resources so the person does not have to navigate every handoff alone.

What happens after an ECM referral?

After a referral is received, the care coordination team reviews the basic need and follows up to learn more. That conversation can clarify the person’s current care team, their immediate concerns, and any practical barrier that needs attention first. It may also identify information that should be shared directly with a clinician or health plan rather than through the referral form. The next step may include confirming eligibility, connecting with the health plan, or identifying the right support for the person.

SAME-DAY CARE

A clearer next step starts here.

Book a visit through the secure patient portal, or call our care team.

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