Coordinated, person-centered support for complex health and social needs
Enhanced Care Management (ECM) is a Medi-Cal care-management service. United And Guided works alongside members in Sacramento to help coordinate care across health care, behavioral health, and community systems — so nothing important falls through the cracks.
A few ways to start
Whether you are a Medi-Cal member, a family member, or a referring provider, there is a clear next step below.
Start Comprehensive Needs Assessment
Tell us about your health, housing, family, employment, education, finances, strengths, and personal goals so United And Guided can better understand your needs and identify appropriate services and resources.
Begin the assessmentSchedule ECM Appointment
Talk with a member of the United And Guided care-management team about whether Enhanced Care Management may be a fit for your situation.
Schedule ECM AppointmentRefer a Member
Providers, family members, care teams, and community partners may submit a secure referral for someone who may benefit from United And Guided's services.
Submit a referralSchedule Collaboration Discussion
Health plans, hospitals, public agencies, and community organizations may schedule a discussion about referrals, coordinated care, contracting, or service partnerships.
Schedule a discussionCare management built around the whole person
Enhanced Care Management, commonly called ECM, is a person-centered care-management service designed to help eligible Medi-Cal members with complex health and social needs coordinate care across health care, behavioral health, community, and social-service systems.
Rather than simply handing someone a list of referrals, United And Guided's ECM team works alongside the member — getting to know their history, priorities, and everyday realities — and helps connect the pieces of care that already exist around them.
ECM support may include:
- Comprehensive assessment
- Person-centered care planning
- Coordination with health care providers
- Behavioral-health coordination
- Medication-related care coordination, when appropriate
- Appointment navigation
- Transitions of care
- Hospital or emergency-department follow-up
- Housing-related coordination
- Food and benefit resource navigation
- Transportation coordination
- Coordination with Community Supports
- Community-resource navigation
- Family and caregiver coordination, when authorized
- Member advocacy
- Health-system navigation
- Social-needs coordination
- Ongoing follow-up toward member-defined goals
ECM is care management — not a replacement for care
Enhanced Care Management does not replace a member's physician, therapist, emergency services, or other licensed clinical providers.
United And Guided's role is to help coordinate and connect the care and services already available to a member, working in partnership with the people already treating them.
ECM is generally intended for members whose needs call for a higher level of coordination
Every situation is different, and no single condition automatically qualifies someone for Enhanced Care Management. In general, ECM may be a fit for Medi-Cal members experiencing a combination of needs, such as:
- Multiple medical needs
- Behavioral-health needs
- Repeated hospital or emergency-department use
- Homelessness or housing instability
- Difficulty coordinating multiple providers
- Pregnancy or postpartum needs, when applicable
- Transition from incarceration or another institutional setting, when applicable
- Serious social barriers affecting health
- Difficulty navigating health-plan or community services
If you are not sure whether ECM is the right fit, the Comprehensive Needs Assessment is a useful place to start — it helps United And Guided understand your situation and point toward the services that may apply.
What to expect
When a member is connected to ECM, United And Guided assigns a care team that gets to know the person, not just their diagnosis or referral. That team works to build a person-centered care plan grounded in the member's own goals, strengths, and priorities.
United And Guided uses closed-loop referrals, meaning that when a member is connected with an outside resource, the care team follows up to confirm the connection was made and to help resolve any barriers that come up. Where appropriate, the care team also arranges warm handoffs — a direct introduction between the member, United And Guided, and the receiving provider or organization — rather than leaving the member to navigate a new relationship alone.
ECM support is flexible and adjusts as a member's needs and goals change over time, including during transitions such as a hospital discharge, a change in housing, or a new diagnosis.
Closed-loop referrals
A referral is followed through to confirmation, not just sent and forgotten.
Warm handoffs
Members are personally introduced to the next provider or resource, whenever appropriate and authorized.
How the ECM pathway typically unfolds
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Referral or inquiry
A member, family member, provider, or health plan submits a referral, or a member reaches out directly.
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Eligibility and authorization review
United And Guided reviews available information to understand whether ECM may apply to the individual's Medi-Cal coverage and circumstances.
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Outreach and engagement
The care team reaches out to introduce the service, answer questions, and begin building a trusted relationship.
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Comprehensive assessment
A full picture of the member's health, social, and personal circumstances is developed together with the member.
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Person-centered care plan
Goals, priorities, and next steps are documented in a plan the member helps shape.
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Care coordination and referrals
The care team coordinates with existing providers and connects the member to applicable resources and Community Supports.
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Follow-up and progress monitoring
The care team checks in regularly to track progress and adjust course as needed.
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Care-plan updates and transition planning
The plan evolves with the member, including planning for what happens if ECM involvement changes or ends.
Provider and community partner collaboration
United And Guided works alongside a wide range of partners to support shared members. Partners may refer members, coordinate shared members when appropriately authorized, request a warm handoff, explore contracting, coordinate outreach, discuss service workflows, or develop referral pathways.
A warm handoff simply means a direct introduction among the member, the referring partner, and the United And Guided team — rather than an anonymous referral left for the member to follow up on alone. United And Guided does not exchange protected health information without appropriate authorization.
United And Guided regularly collaborates with:
Common questions about Enhanced Care Management
No. Enhanced Care Management is a care-management service available to some eligible Medi-Cal members. It does not replace your Medi-Cal health plan, primary-care provider, specialists, behavioral-health providers, or other members of your healthcare team. United And Guided works with the member and, when appropriately authorized, with existing providers to help coordinate care and services.
No. Having Medi-Cal by itself does not automatically qualify someone for Enhanced Care Management. Eligibility depends on the member's circumstances, applicable ECM eligibility requirements, health-plan review, authorization requirements, and other factors. United And Guided can help review the available information and identify appropriate next steps.
No. ECM is intended to help coordinate care around you, not replace your existing healthcare providers. Your United And Guided care team may help you communicate with providers, prepare for appointments, follow up on referrals, coordinate services, or address barriers that make it difficult to access care.
Yes. Healthcare providers, care teams, family members, community organizations, and other partners may submit a referral when they believe someone may benefit from United And Guided's services. A referral starts the review process but does not guarantee ECM eligibility or authorization.
No. Submitting a referral, completing the Comprehensive Needs Assessment, or scheduling an appointment does not guarantee enrollment in ECM. Eligibility, authorization, coverage, and service availability depend on the member's situation, applicable Medi-Cal requirements, and health-plan review.
The first conversation is an opportunity to learn about the member's circumstances, priorities, strengths, concerns, and goals. United And Guided may ask about areas such as healthcare, behavioral health, housing, transportation, food, family support, benefits, and other social needs. The team can then explain possible next steps and, when appropriate, begin developing a person-centered care plan with the member.
No. Enhanced Care Management is a care-coordination service and is not an emergency-response service. If someone is experiencing a medical or behavioral-health emergency that requires immediate assistance, they should use the appropriate emergency services or seek emergency medical care.
Other ways United And Guided may help
Ready to take the next step?
Start with the Comprehensive Needs Assessment, schedule a consultation, or submit a referral — United And Guided will help identify what applies to your situation.
Service eligibility, authorization, availability, and payment depend on the individual's needs, location, health plan, referral source, applicable coverage requirements, and available funding. Completing an assessment, submitting a referral, or scheduling an appointment does not guarantee enrollment, authorization, coverage, payment, or receipt of a particular service. United And Guided will review available options and next steps with each individual or referring partner.