CalAIM
Enhanced Care Management (ECM) +
Community Supports (CS)
Supporting whole-person care.
The whole-person care approach of CalAIM focuses on addressing social drivers of health (like housing stability and access to essential services) for individuals with complex health and social needs.
Who qualifies for CalAIM?
Services are offered to eligible Medi-Cal members who meet specific populations of focus, as defined by the CalAIM program.
Populations of focus include:
Homeless families or individuals experiencing homelessness
Individuals at risk for avoidable hospital or emergency department utilization
Individuals experiencing serious mental health and/or substance use disorder needs (SMI)
Individuals experiencing Substance Use Disorder (SUD)
Children/youth involved in child welfare
How referrals work
We work closely with referring partners and managed care plans to review referrals, confirm eligibility, and coordinate services.
Members & families
Medi-Cal members can inquire about eligibility through their Medi-Cal managed care plan, primary care provider, or care team
Partners & providers
Healthcare providers, managed care plans, and community partners may submit referrals or contact us for guidance on referral pathways and available services.
Services & supports
EA Family Services provides intensive care coordination and housing supports for Medi-Cal members with complex health and social needs through two core service categories: Community Supports and Enhanced Care Management.
Enhanced Care Management (ECM)
The goal of ECM is to improve the member’s health and social outcomes. ECM provides seven core services to enrolled members:
Outreach and engagement
Comprehensive assessment and care management plan
Enhanced care coordination
Health promotion
Comprehensive transitional care
Member and family support
Coordination of and referral to community and social support services
ECM Lead Care Managers work collaboratively with each member and a multidisciplinary team to develop a personalized care plan with Specific, Measurable, Achievable, Relevant, and Timely (SMART) goals.
The care plan addresses healthcare and supportive service needs, including:
Coordination of primary and specialty medical care
Dental, mental health, and substance use services
Behavioral health support
Job training and vocational services
Long-term services and supports, including housing resources
Care team and client/family team meetings
Housing navigation and supportive housing coordination
Life skills development and education support
Appointment reminders and transportation assistance
Accompaniment to critical appointments
Community Supports (CS)
Community Supports address social drivers of health and help Medi-Cal members maintain stable living environments. The CS Program offers three housing services:
Housing Transition Navigation Services
Housing Transition Navigation Services help members find, apply for, and secure housing. The specific services each member receives are determined by their individual needs but may include:
Assessing the member’s housing needs, preferences, and any challenges to find or keep housing.
Create a housing support plan based on this assessment.
Help the member search for housing and review available options.
Support the member in securing housing, including completing applications and gathering necessary documents (like a Social Security card or birth certificate).
Find and connect the member to resources for housing, such as Transitional Rent, housing vouchers and other assistance programs.
Housing Deposit Services
Housing Deposit services assist with identifying, coordinating, securing or funding one-time services and modifications necessary to enable a person to establish a basic household. The services and goods provided to a member must be based on an individualized assessment of needs but may include:
Security deposits required to obtain a lease on an apartment or home.
Services or goods necessary for the individual’s health and safety.
Application fees to cover the cost of the lease application.
Note: Limitations and exlusions to this service are based on the Participants Health Plan provider.
Housing Tenancy and Sustaining Services
Housing Tenancy and Sustaining Services support members in maintaining safe and stable housing after they have secured a place to live. The specific services each member receives are determined by a personalized assessment of their needs but may include:
Identify and address behaviors that may threaten housing stability—such as late rent payments, hoarding, substance use, or other lease violations.
Educate and train members on the roles, rights, and responsibilities of tenants and landlords.
Coordinate with landlords and care/case managers (such as Enhanced Care Management providers or coordination or care program case managers) to resolve issues that could affect housing stability.
Advocate for members and connect them to community resources to prevent eviction when housing is at risk.
Typical participant journey
Referral
Participants may be referred to our program by their Managed Care Plan, other service providers, or they may refer themselves using our contact form or calling the EA intake line.
Intake
An EA Intake Coordinator will review the referral to access eligibility and support in submitting an authroization request to the health plan.
Enrollment
Once an authorization request has been submitted, the participant will be assigned a dedicated Lead Care Manager (LCM) to begin program services. Authorization requests are reviewed by the health plan and may be approved if the participant meets the eligiblity requirments.
Program Services
The assigned LCM will support participants in navigating the healthcare system, completing assessments, developing a personalized care plan, providing health education, and helping access needed resources and services.
Graduation
Participants may graduate from the program based on time enrolled, completion of goals, health improvements, or by choice at any time.
What makes our CalAIM services different?
Too often, individuals with complex health and social needs struggle to navigate disconnected systems of care.
We understand that improving outcomes requires more than referrals—it requires consistent coordination, strong relationships, and a whole-person approach.
EA works closely with members and partners to deliver responsive, individualized support that promotes stability and long-term well-being.
Individualized care coordination tailored to each member’s health, behavioral, and social needs
Dedicated Lead Care Managers who provide consistent guidance and support
Whole-person care approach connecting medical, behavioral health, and social services
Proactive engagement and follow-up to support progress and reduce gaps in care
Strong partnerships with managed care plans, providers, and community organizations
Housing-focused Community Supports that promote stability and long-term housing success.