• Frequent Hospital or ER Utilizers: People with patterns of high healthcare use, such as those with multiple emergency room visits or hospital stays in a short period . Often, these are individuals with poorly controlled chronic illnesses (like heart failure, diabetes, or severe asthma) who end up in the hospital frequently. ECM works to break this cycle by coordinating proper outpatient care, medication management, and social services to stabilize their health.

• Serious Mental Illness or SUD: Individuals living with serious mental health conditions (e.g. schizophrenia, bipolar disorder) or substance use disorders, along with significant social factors affecting their health . For adults, this may include conditions like severe depression or opioid addiction with a risk of hospitalization or institutionalization. For children and youth, this can include serious emotional disturbance. ECM ensures these members get connected to mental health treatment, substance recovery services, and support for needs like housing or vocational training, while coordinating with physical healthcare providers.

• Transitioning from Incarceration: Adults and young adults who are re-entering the community from jail or prison (or juvenile detention) and have significant health, mental health, or substance use needs . This population often has difficulty accessing care after release. Through ECM, we engage these individuals ideally before or just after they return to the community, helping them find doctors, continue medications or treatments, and connect with services like job training or housing, to reduce chances of health crises or re-incarceration .

• At Risk for Institutionalization (Long-Term Care): Older adults or adults with disabilities who are living in the community but are at risk of placement in a nursing home or long-term care facility . They might meet nursing facility level-of-care criteria due to serious medical conditions or functional impairments. ECM supports these individuals by coordinating in-home services, caregiver support, and home modifications or other resources so they can continue living safely at home for as long as possible.

• Nursing Home Residents Transitioning to Community: Individuals currently residing in a nursing facility who want to move back to the community and are good candidates for a successful transition . Our team works with the member, their family, and facility discharge planners to arrange everything needed for a smooth transition – from finding housing to setting up home healthcare, community support, and follow-up care – making sure the person can live independently with proper supports.

• Children with Complex Needs (CCS/CCS Whole Child Model): Children and youth enrolled in California Children’s Services (CCS) or the CCS Whole Child Model who have additional needs beyond their primary medical condition . These are kids with serious illnesses or disabilities (for example, cancer, congenital heart disease, cystic fibrosis) who often see multiple specialists. ECM provides care coordination that goes beyond their medical treatments – including addressing family needs, schooling or developmental services, transportation to appointments, and more.

• Child Welfare-Involved Youth: Children and youth who are involved in the foster care or child welfare system . This includes kids currently in foster care, those who have recently reunified with family, or young adults who aged out of foster care up to age 26. These youth frequently face instability and gaps in care during transitions. Through ECM, they receive extra support coordinating medical, behavioral health, and social services (e.g. counseling, mentorship, education support) to promote stability and well-being as they navigate life changes.

• Pregnant and Postpartum Individuals (Birth Equity Focus): People who are pregnant or within one year postpartum and are at elevated risk of poor outcomes due to health disparities . California has identified that women of color, especially Black and Indigenous women, experience higher rates of maternal complications. Under the ECM Birth Equity Population of Focus, expectant/new mothers facing such risks receive enhanced care coordination. CCHC’s team works with prenatal care providers, offers health education and parenting support, connects families to resources like nutrition assistance or home visiting programs, and generally helps mothers and babies get off to a healthy start.

Each of these Populations of Focus has specific eligibility definitions (set by the Department of Health Care Services). CCHC strictly adheres to those guidelines to identify and enroll members into ECM. By targeting these populations, we ensure our efforts are directed where they can make the greatest impact. If you or your patient falls into one of these categories, CCHC is ready and equipped to provide comprehensive care management tailored to those unique needs.

(For more detailed eligibility criteria for each Population of Focus, please refer to official DHCS guidelines or contact us – we can help determine qualification on a case-by-case basis.)