Enhanced Care Management

Enhanced Care Management delivers personalized support that bridges healthcare and essential daily needs for Medi-Cal members. Our dedicated care navigation team coordinates comprehensive services and resources, ensuring individuals receive the right support to maintain independence while achieving better health outcomes.

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Partnering for Better Health with Enhanced Care Management

At Care Partners Medicine, our Enhanced Care Management program is designed to provide comprehensive, patient-centered care that addresses the unique and complex needs of each individual. Through a collaborative approach involving primary care physicians, nurse practitioners, and a multidisciplinary team, we ensure that every aspect of a patient’s health is meticulously managed. Our program emphasizes quality assessment, performance improvement, and continuous monitoring to deliver effective, safe, and satisfying healthcare experiences. By integrating clinical expertise with social support, we strive to guide our patients towards optimal health outcomes and a higher quality of life.

What Our Care Management Offers You

Quality Assessment

Each year we work in conjunction with our PACE partners and develop a Quality Assessment and Performance Improvement (QAPI) plan to meet the requirements of the State and Federal participation Guidelines

Group Monitors

Our Group monitors performance against measures such as use of services, satisfaction, assessment data, and the safety and effectiveness of all services delivered to participants

Analyze

We identify initiatives, set goals, measure baseline performance, and monitor progress. These objectives are tracked on a bi-annual basis, and are shared throughout the year

What We Provide

  • Our Primary Care Physicians and Nurse Practioners “Quarterback” an impressive clinical and social supportive multidisciplinary team to guide the patient’s care, by creating a comprehensive approach for each complex patient’s needs
  • Providers navigate routine care and are the point providers for all specialty care and consults must run through their oversight to assure care continuity
  • When hospitalized, patients rely on our providers to navigate their care to a successful discharge home, or “the place” they call home
  • Our providers measure quality care first with cost effective medicine to not over utilize unnecessary and nonbeneficial services
  • Critical to success is the provider’s focus on guiding all medication administration and patient feedback

ECM Assists With

Social Resource Support

Meals & Grocery Support

Transportation Services

Primary Care, Mental Health, & Specialty Referrals

Placement & Day Programs

Emergency Response Systems (e.g. buttons, pendants, bracelets)

Housing Resources

Guidance with Benefits, CalAIM Services and other Medi-Cal Programs

Support & Benefits

Who We Support

  • Members who have experienced 3 or more unplanned hospital visits in the last 6 months
  • Members with 5 or more ED visits in the last 6 months
  • Members living at home who meet Skilled Nursing Facility (SNF) Level of Care Criteria AND(bolded) are actively experiencing at least one complex social or environmental factor impacting their health
  • Adult nursing facility residents who desire to live in a lower level of care setting, and(bolded) would be able to successfully do so with appropriate community resources

What Are The Benefits

  • Comprehensive Healthcare – Integration of both clinical care and social services in one program
  • Personalized Care Planning – Care managers work one-on-one with members to develop individualized health plans
  • Resource Navigation – Direct assistance connecting to healthcare services, community programs, and social support
  • Improved Access: Breaking down barriers to receiving necessary medical care and support services
  • No-Cost Benefit – Available at no cost to eligible Medi-Cal members
  • Health Equity Focus – Working to ensure all members receive fair, equal access to quality healthcare
  • Continuous Support – Regular check-ins and ongoing assistance from dedicated care managers.

Meet Our Advanced Care Team

Vanessa Mandal, MD,
CMD, MS

Medical Director

Seema Siraj, MD

Medical Director

Martin Tang, DO

Physician

Charlisa Brothers,
FNP-C

Nurse Practitioner

Chrystal Zhang, FNP

Nurse Practitioner

Rani John, NP

Nurse Practitioner

Reni Zachariah, MSN-FNP-C

Nurse Practitioner

Stembile “Faith” M. FNP-BC, MSN, RN, PHN

Nurse Practitioner

DR. Lineth Florian, MD

Physician

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