Celebrating our first 100+ patients!
Launched in July 2025, the Heluna Health/Community Translational Research Institute (CTRI)’s ECM Program at the Vital Space is a cornerstone of California’s CalAIM initiative, designed to deliver whole-person, integrated care to individuals with complex medical, behavioral, and social needs. Our program emphasizes trust-building, culturally responsive engagement, proactive outreach, and care coordination, ensuring that high-need members receive timely and coordinated support.
Through structured outreach, care coordination, and strong partnerships across Riverside County, the Vital Space ECM Program helps members overcome barriers such as homelessness, chronic illness, behavioral health challenges, and limited access to essential services. This approach aligns with IEHP and DHCS requirements while advancing CTRI’s mission to improve health equity and outcomes for vulnerable communities.
Priority Populations (DHCS Populations of Focus)
These are populations that face significant barriers to care, making targeted outreach and coordinated support essential for improving health outcomes.
CTRI’s ECM Program prioritizes the following groups (especially children and adolescents):
Individuals and families experiencing homelessness
Individuals at risk for avoidable hospital or ED use - High Utilizers
Individuals with serious mental illness (SMI) and/or substance use disorder (SUD)
Adults at risk of long-term care institutionalization
Nursing facility residents transitioning back into the community
Children and youth in child welfare or CCS with high behavioral/physical health needs
Individuals identified in the birth equity population
Coverage Area and Geographic Prioritization
The Vital Space ECM Program provides county-wide coverage across Riverside County, with focused outreach in IEHP-assigned ZIP codes. Priority regions include:
Jurupa Valley
Riverside City
Corona
Temecula
Figure 1. Map Showing Coverage Area of ECM Program
Figure 2. Map Showing ECM Program Coverage Area
CTRI ECM Program Enrollments
A total of 113 clients were enrolled in the ECM program from July 2025 to February 2026.
ECM Program Achievements
Driving measurable impact for high-need members across Riverside County
The Vital Space ECM Program has demonstrated strong early outcomes since launching in July 2025, reflecting CTRI’s commitment to whole-person, equity-centered care. Through coordinated outreach, care management, and cross-sector collaboration, the program has achieved the following measurable results:
1. Strengthened Access to Community Resources
CTRI’s ECM team has connected more than 90 members to essential community and social service resources, including:
Housing navigation and homelessness support services
Transportation assistance for medical and social needs
CalFresh and CalWORKs enrollment support
Linkages to local food pantries and food banks
These connections have resulted in improved stability, reduced unmet social needs, and increased engagement in preventive care.
2. Improved Behavioral Health Outcomes
The program has facilitated timely referrals to behavioral health services, including therapy, psychiatry, and substance use treatment. Members receiving these services have shown measurable improvements, demonstrated by:
Reduced PHQ-9 scores (depression)
Reduced GAD-7 scores (anxiety)
Improved PSC-35 scores for children/youth (3 – 11years) behavioral health
These outcomes reflect the program’s success in addressing mental health needs through integrated, person-centered care.
3. Enhanced Access to Medical and Therapeutic Care
ECM care managers have supported members in scheduling and attending primary care and specialty appointments, reducing delays in care and improving continuity. Members have also been successfully referred to:
Physical Therapy (PT)
Speech Therapy
Occupational Therapy
Regional Center services, when applicable
These coordinated efforts have contributed to better chronic disease management, improved functional outcomes, and increased adherence to care plans.
