Whole-person support
A lot to manage. You don't have to handle it alone.
When healthcare, housing, benefits, transportation, mental health, and everyday needs start overlapping, Atlas helps bring the pieces together. Your care manager works alongside you to coordinate services, connect you with resources, and help you navigate what comes next.
What this can feel like
- Not knowing who to call when you need help.
- Getting bounced between providers, programs, and services.
- Trying to manage healthcare while dealing with other needs.
- Housing, food, or rides getting in the way of getting care.
Formally, this service is Enhanced Care Management (ECM). You do not need to know the program name to ask for help.
What we do
How Atlas helps
One person owns your plan
A Lead Care Manager coordinates your providers, referrals, and follow-ups so you are not the one chasing them.
Your providers get connected
Primary care, specialists, behavioral health, pharmacy, and hospitals work from the same care plan.
Transitions get handled
After a hospital, ER, or skilled nursing stay we organize medications and follow-up visits quickly.
Life needs count as health needs
We help request housing navigation, food resources, transportation, and benefits alongside medical care.
Who may benefit
Who this is for
- Members with multiple chronic conditions
- Recently discharged from hospital or skilled nursing facility
- Experiencing homelessness or housing instability
- Living with serious mental illness or substance use disorder
- Children and youth with complex behavioral or medical needs
- Adults transitioning out of incarceration or institutional care
- Older adults managing multiple medications and providers
- Members with frequent ER visits in the past 6 months
What's included
Support for whatever you're carrying
Dedicated Lead Care Manager
One care manager owns your care plan end-to-end — coordinating every provider, every referral, and every follow-up so you never have to repeat your story.
Care coordination across providers
We connect primary care, specialists, behavioral health, pharmacies, and hospitals into a single plan so the right hand always knows what the left hand is doing.
Help with prescriptions & referrals
From prior authorizations to specialist appointments to medication pickups, your care team handles the logistics that usually fall to patients.
Behavioral health integration
Mental health support is built into your care plan from day one — not a separate referral you have to chase down on your own.
Transitions of care support
Hospital, ER, and skilled nursing discharges are followed up within days — medication reconciliation, follow-up visits, and home support arranged before you walk out the door.
Help with housing, food & benefits
Your Lead Care Manager connects you to housing navigation, food resources, transportation, and benefits enrollment — addressing the social drivers that affect your health.
How to get it
Getting started takes one step
- 1
Check if you qualify
Answer a few short questions online, or call us and we will check with you.
- 2
Talk with a real person
Someone from Atlas follows up to understand your situation and answer questions.
- 3
Get assigned a care manager
Once your Medi-Cal plan approves care management, you are matched with a Lead Care Manager.
- 4
Build your plan together
You set the priorities; your care manager starts making the calls and appointments.
Eligibility, authorization, and provider assignment are determined by your Medi-Cal managed care plan.
Who we help
You may be a good fit for this support if...
Coming Home After Incarceration
Recently released or preparing for release? We can help coordinate healthcare, medications, benefits, transportation, and other support as you transition home.
Experiencing Homelessness or Unstable Housing
If you're without stable housing or worried about where to stay, we can help coordinate your care and connect you with available housing and community resources.
Mental Health & Recovery Support
If you're managing serious mental health or substance use needs, we can help bring your healthcare, behavioral health, recovery services, and everyday support together.
Pregnancy & Postpartum Support
Pregnant or recently had a baby? We can help coordinate your healthcare and connect you with additional support during pregnancy and after delivery.
Frequent ER Visits or Hospital Stays
If you've been to the ER or hospital several times, we can help coordinate follow-up care, medications, appointments, and other support to help you stay well at home.
Two minutes, no paperwork
Let's see if care management is available to you.
For providers, partners & anyone who wants the details
Detailed program information
Engagement
We keep you actively involved in your own care through regular communication, shared decision-making, education, and consistent follow-up — so nothing falls through the cracks.
Planning
Your Lead Care Manager works with you to build a personalized care plan: assessments, goal setting, treatment options, and coordination across every provider on your team.
Support
Emotional, informational, practical, social, and behavioral support — tailored to what you actually need to manage your health day to day.
Education
Health literacy, condition-specific guidance, medication education, and clear explanations of treatment options so you can make confident, informed decisions.
Connections
We build trust through empathy, cultural competence, and personalized care — connecting you to the right clinicians, specialists, and community partners.
Transportation
Reliable, accessible rides to medical appointments coordinated through your care team — so getting there is never the reason you skip a visit.
Social Services
Case management, counseling, housing support, food assistance, financial aid, and legal navigation to address the social drivers of your health.
The challenge, in statewide data
Sources: California Department of Health Care Services (DHCS), Medi-Cal, and CalAIM program data.
How Atlas addresses it
One Lead Care Manager — not a phone tree
Every member gets a single point of contact who owns their care plan end-to-end. No transfers, no re-explaining your story, no falling through the cracks between specialties.
We meet you in your community
In-home visits, bilingual outreach, and culturally matched staff turn Medi-Cal's promise into something members actually experience — not paperwork they have to navigate alone.
Care that travels with the member
From hospital discharge to housing placement to behavioral health, our team stays with the member across every transition so progress compounds instead of resetting.
Other ways we help
All servicesCommunity Supports
Housing, meals, and home modifications—the resources that make daily life livable.
Behavioral Health
Mental health, substance use, and emotional support—body, mind, and spirit.
Community Health Workers
Culturally aligned, person-centered care that bridges health and social services.
Medical Transportation
Reliable, safe transport to and from medical appointments—because access shouldn't be a barrier.
Lifeline Services
Help qualifying Medi-Cal households enroll in the California LifeLine Program for discounted phone and broadband service.