Monterey County’s Whole Person Care pilot program (WPC) transitioned to Enhanced Care Management (ECM) under CalAIM on January 1, 2022. CalAIM is a program for Medi-Cal enrollees that coordinates access to services to address physical, behavioral, developmental, dental, and long-term care needs in an equitable manner.

We appreciated the opportunity to serve our community through our participation in the WPC. Previously, we accepted referrals for WPC directly from community partners and members, however this process and the eligibility requirements have changed with ECM.  Central California Alliance for Health (CCAH), the Medi-Cal Managed Care Program serving Monterey County, will assign clients directly to an ECM provider, including Monterey County Health Department, Public Health Bureau.  To refer someone to ECM, please contact CCAH directly at 831-430-5512.

ECM clients will partner with a nurse case manager to actively participate in improving their health outcomes. Some of these services include:

• Conducting a comprehensive assessment, care plan, and discharge plan
• Working with the client and care team to reach client’s health goals
• Making referrals to community partners and CCAH for community supports, such as housing and sobering center
• Accompanying client to medical visits
• Providing health education around medical diagnosis
• Assisting in obtaining medications and provide instruction on how to take correctly
• Assisting in arranging for transportation

There will be three populations of focus served beginning January 2022:

• Individuals experiencing homelessness who have multiple chronic diseases.
• High utilizers of the hospital emergency and inpatient services.
• Adults who have a serious mental health condition or have a hard time with drug or alcohol use.

We look forward to continued community service through ECM. 

More information about CalAIM and ECM can be found here: https://www.dhcs.ca.gov/CalAIM/Pages/calaim.aspx

 

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ARCHIVED - Whole Person Care Information

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Whole Person Care (WPC) is a program of Monterey County Health Department and its community partners to provide comprehensive case management for our county’s most vulnerable Medi-Cal recipients who are high users of hospital and emergency department facilities. This focus population may also:

 

• be homeless/chronically homeless,
• have mental illness or substance use disorders or both,
• have multiple chronic disease

The WPC program Registered Nurse case managers assess WPC enrollees for health, housing, and social services needs, and then provide warm hand-offs to primary care clinics, mental health/substance abuse therapists, social services, housing supports and placement, and employment training. Case managers will also assist WPC enrollees will be assisted in their normal environments with benefit assessments, setting and keeping appointments, transportation, food and nutrition, peer support groups, and housing counseling and skill development training.

New strategies to be developed by WPC include cross-system data sharing systems between WPC case managers, four hospitals located within the county, Monterey County Clinic Services and community clinics, substance treatment providers, and homeless services providers. New facilities include an 8-bed sobering center for stays up to 24 hours, a 6-bed respite center for medically fragile WPC enrollees who need are discharged from a hospital but are unable to recover on their own.

Approximately 1,200 individuals