Enhanced Care Management (ECM)
Personalized Support for Better Health, Stability, and Independence
At Inside Out Behavior Services, our Enhanced Care Management (ECM) program provides personalized, whole-person support to eligible Medi-Cal members with complex medical, behavioral health, and social needs.
A major focus of our ECM program is supporting individuals experiencing homelessness or housing instability. We understand that it can be extremely difficult to manage medical appointments, medications, behavioral health needs, and everyday responsibilities without safe and stable housing.
Our care management team works directly with members in the community to help address immediate needs, coordinate healthcare, connect members with housing-related resources, and build a path toward greater health and stability.
Supporting Individuals Experiencing Homelessness
People experiencing homelessness often face multiple barriers to accessing consistent healthcare and social services. Inside Out Behavior Services takes a hands-on, person-centered approach to helping members overcome these barriers.
Our ECM team can help members who are:
- Experiencing homelessness
- Living in shelters or temporary housing
- Staying in vehicles, motels, or other unstable living situations
- At risk of losing their housing
- Frequently using emergency rooms or hospitals
- Managing chronic medical conditions while unhoused
- Experiencing behavioral health or substance use challenges
- Having difficulty accessing healthcare, medications, transportation, food, or benefits
Our goal is not simply to provide referrals. We work alongside each member to help connect the different services they need and provide ongoing support throughout the process.
Our ECM Services
Comprehensive Care Management
We take the time to understand each member's medical, behavioral health, housing, and social needs.
Our care managers develop an individualized care plan based on the member's priorities, challenges, and goals and continue working with the member as those needs change.
Housing and Homelessness Resource Coordination
Housing instability can have a major impact on a person's physical and behavioral health.
Our team helps members navigate available housing and homelessness resources and can coordinate with shelters, outreach programs, housing organizations, healthcare providers, health plans, and community agencies.
Depending on the member's needs and eligibility, we may assist with connections to:
- Emergency and temporary shelter resources
- Housing navigation services
- Housing-related Community Supports
- Homeless outreach programs
- Transitional and supportive housing resources
- Benefits and financial assistance programs
- Food and nutrition resources
- Transportation
- Identification and documentation resources
- Other community-based services
Care Coordination
Managing multiple providers and services can be especially challenging for members experiencing homelessness.
We help coordinate communication and services between:
- Primary care providers
- Specialists
- Hospitals and emergency departments
- Behavioral health providers
- Substance use treatment providers
- Pharmacies
- Health plans
- Social service agencies
- Housing and homeless service organizations
- Community-based organizations
Behavioral Health Support and Coordination
Inside Out Behavior Services recognizes the close connection between behavioral health, physical health, housing stability, and overall well-being.
Our ECM team can help members connect with appropriate behavioral health services and coordinate care with mental health and substance use treatment providers when needed.
Health Promotion
We help members better understand their health conditions, medications, treatment plans, and available resources.
- Our team encourages members to become active participants in their healthcare while helping reduce the barriers that may prevent them from receiving consistent treatment.
Transitional Care Support
Transitions from hospitals, emergency departments, rehabilitation facilities, behavioral health facilities, or other care settings can be particularly difficult for people without stable housing.
Our team can help members with:
- Follow-up medical appointments
- Medication coordination
- Transportation
- Connection to temporary housing or community resources
- Communication with providers
- Continued behavioral health services
- Other post-discharge needs
- Our goal is to reduce gaps in care and help prevent avoidable emergency room visits and hospital readmissions.
Community and Social Service Connections
Health goes beyond medical care. Our team helps connect members with resources that address the social factors affecting their health and quality of life, including:
- Housing and homelessness services
- Food and nutrition assistance
- Transportation
- Behavioral health services
- Substance use treatment resources
- Benefits and public assistance
- Adult Day Health Care programs
- Disability-related services
- Community-based support programs
- Other health and social services
Member and Family Support
When appropriate and with the member's involvement, we work with family members, caregivers, and other trusted individuals to strengthen the member's support system.
Who Can Benefit From ECM?
Enhanced Care Management is available to eligible Medi-Cal members who meet applicable ECM criteria.
Inside Out Behavior Services places a strong emphasis on reaching and supporting members experiencing homelessness or housing instability, particularly individuals who may also have complex medical, behavioral health, or social needs.
ECM may also support eligible individuals experiencing circumstances such as:
- Frequent hospital or emergency department utilization
- Serious behavioral health needs
- Substance use challenges
- Complex or chronic medical conditions
- Difficulty navigating multiple healthcare systems
- Transition from institutional or facility-based care
- Significant social needs that interfere with access to healthcare
Eligibility is determined according to applicable Medi-Cal and participating health plan requirements.
Meeting Members Where They Are
At Inside Out Behavior Services, we believe effective care management starts by meeting people where they are.
For members experiencing homelessness, expecting them to navigate a complicated healthcare system alone may not be realistic. Our team works to engage members in the community and maintain ongoing contact whenever possible.
We take a compassionate, respectful, culturally responsive, and person-centered approach while helping each member move toward greater health, stability, and independence.
How Our ECM Team Can Help
Our care managers can:
- Complete a comprehensive assessment of the member's needs
- Develop an individualized care plan
- Help coordinate healthcare appointments
- Communicate with medical and behavioral health providers
- Help members understand medications and treatment plans
- Connect members with housing and homelessness resources
- Coordinate transportation
- Connect members with food and other basic necessities
- Assist with accessing community programs and benefits
- Follow up after emergency room visits or hospitalizations
- Help members navigate Medi-Cal and the healthcare system
- Advocate for members experiencing barriers to care
- Maintain ongoing communication and follow-up
A Partner in Health and Stability
At Inside Out Behavior Services, we believe every individual deserves access to compassionate, coordinated care regardless of their housing situation.
For members experiencing homelessness, our goal is to create a consistent point of support — connecting healthcare, behavioral health, housing resources, and community services so members do not have to navigate these systems alone.
Refer a Member or Learn More
If you or someone you support is a Medi-Cal member who may benefit from Enhanced Care Management, Inside Out Behavior Services is here to help.
We welcome referrals for individuals experiencing homelessness, housing instability, complex health conditions, behavioral health needs, and other qualifying circumstances.
Contact Inside Out Behavior Services today to learn more about ECM services, eligibility, or how to submit a referral.
Phone: 888-901-9910
Email:
admin@insideoutbehavior.com
Referrals Welcome
We welcome referrals from:
Healthcare providers • Hospitals • Health plans • Behavioral health providers • Homeless shelters • Outreach organizations • Social service agencies • Community organizations • Family members • Members themselves