Thursday, June 20 | Care Coordination, Human Services, Legislative/Policy, Interoperability

Enhanced Care Management: Care Coordination for California's Most Vulnerable

By AJ Peterson, SVP and GM, CareGuidance

As we continue our blog series on Medi-Cal enhancements, let’s look at another program, Enhanced Care Management (ECM). Like CARE Court, which is a court-mandated process, ECM is a whole-person approach to healthcare for individuals, aimed at improving care coordination across multiple settings and improving outcomes for California’s most vulnerable populations.

Did you know that half of all Medi-Cal spending goes to members with the highest risk? These individuals have complex needs and generally require treatment across multiple care settings - such as mental health, physical health and substance use. ECM is a statewide Medi-Cal benefit that provides case management services for these members, improving outcomes while streamlining costs.

To qualify for ECM, members must belong to one or more high-risk “populations of focus,” such as:

· Individuals and families experiencing homelessness

· Individuals at risk for avoidable hospitalizations

· Individuals with serious mental health and/or substance use disorder needs

· Individuals transitioning from incarceration

· Adults living in the community who are at risk for long-term institutionalization

· Adult nursing facility residents transitioning to the community

· Children and youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CSS condition

· Children and youth involved in child welfare

· Birth equity population

Every member eligible for ECM receives a lead care manager who coordinates their services. The Providing Access and Transforming Health (PATH) initiative helps optimize service delivery by funding care across the community, from homeless shelters to non-profit organizations to county agencies. Those who don’t qualify for ECM may still be eligible for Community Supports, which assist with nutrition, housing and other health-related needs.

ECM is all about care coordination, and providers will need the tools to meet members’ complex needs. For example, interoperability using your electronic health record (EHR) will allow you to coordinate outreach, enrollment and transitions with easy record-sharing. Population Health Management tools can help your staff flag and develop efficient protocols for populations of focus.

These solutions also allow you to compile clinical, financial and operational data, with near real-time insights for reports or sharing with partner organizations. Care partners will also benefit from a complete, longitudinal record of each individual, which care coordination and robust data make possible.

Even more importantly, these analytic and reporting tools systematically aggregate data to segment risks in populations and stratify by risk levels, allowing timely interventions. This allows your staff to flag and develop more efficient protocols for specific conditions.

Finally, much of the process can actually be automated, increasing efficiency and avoiding errors. You can assign caseloads, generate reports and automate entire workflows.

ECM is expected to positively impact the lives of many at-risk Californians. It will increase cost-effectiveness and efficiency, while improving service delivery for individuals who can sometimes fall through the cracks. By giving each member a dedicated lead care manager to coordinate their physical health, mental health and social services, ECM helps individuals get the right care at the right time in the right setting.