Enhanced Care Management
What is Enhanced Care Management?
California Advancing and Innovating Medi-Cal (CalAIM) is a new initiative by the Department of Health Care Services (DHCS) to improve the quality of life and health outcomes of Medi-Cal members by implementing a broad delivery system, program, and payment reform across the Medi-Cal program. CalAIM establishes the framework to address social determinants of health and improve health equity statewide.
Enhanced Care Management (ECM) is a whole-person, interdisciplinary approach to care that addresses the clinical and nonclinical needs of members with the most complex medical and social needs. ECM provides systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered.
What are ECM Services?
The goal of ECM is to coordinate all primary, acute, behavioral, developmental, oral, social needs, and long-term services and supports for members, including participating in the care planning process, regardless of setting. ECM is intended to be interdisciplinary, high-touch, person-centered, and provided primarily through in-person interactions with members where they live, seek care, and prefer to access services.
ECM eligible members will be assigned an ECM provider and a Care Manager who will assess a member’s needs to best support their health care and social needs. See below to learn more about each ECM core service.
Outreach and Engagement: Outreach and engagement for ECM include active and progressive attempts to connect with and engage with members who are eligible for ECM, demonstrating a culturally and linguistically competent approach to build trust.
Comprehensive Assessment and Care Management Plan: Following successful engagement with the member, Lead Care Managers complete a comprehensive biopsychosocial assessment of member needs and engage the member in creation of a person-centered care plan that outlines the member’s strengths, risks, needs, and goals.
Enhanced Coordination of Care: Enhanced Coordination of Care includes the services necessary to implement the care plan, including ensuring care is continuous and integrated among all service providers. ECM Lead Care Managers support coordination across the continuum of care, including primary care, physical and developmental health, mental health, SUD treatment, LTSS, oral health, palliative care, and necessary community-based and social services, including housing, as needed.
Health Promotion: Health promotion activities encourage and support members receiving ECM to make lifestyle choices based on healthy behavior, with the goal of motivating members to successfully monitor and manage their health. Examples include services like coaching, health education, teaching new skills, and connection to resources.
Transitional Care Services: Transitional care services are intended to support members as they transition between care settings or from one level of care to another, from the point of discharge planning until they are successfully connected to all needed services and supports. This can include discharges from hospitals, institutions, other acute care facilities, and SNFs to home or community-based settings, Community Supports, post-acute care facilities, or LTC settings.
Member and Family Supports: Member and Family Supports include activities that ensure the ECM member and family/support are knowledgeable about the member’s conditions, with the overall goal of improving their adherence to treatment and medication management.
Coordination of and referral to Community and Social Support Services: Coordination of and referral to community and social support services involves determining appropriate services to meet the needs of members receiving ECM, to ensure that any present or emerging social factors can be identified and properly addressed.
Who can receive ECM?
DHCS has established specific criteria for ECM eligibility. To be able to enroll in ECM, individuals must meet criteria for at least one of the ECM Populations of Focus. ECM is currently available for the following Populations of Focus:
- Individuals and families experiencing homelessness
- Adults with avoidable emergency department (ED) and hospital utilization
- Adults diagnosed with serious mental health or substance use disorder (SUD)
- Adults with intellectual and developmental disabilities who also qualify for another ECM Population of Focus
- Adult pregnant and postpartum individuals at risk for adverse perinatal outcomes who also qualify for another ECM Population of Focus
- Adults living in the community who are at risk for long-term care and institutionalization
- Adult Nursing facility residents transitioning to the community
In July 2023, the following Populations of Focus become eligible for ECM:
- Children, youth, and families experiencing homelessness
- Children and youth at risk for avoidable hospital or emergency department utilization
- Children and youth with serious mental health and/or substance use disorder (SUD)
- Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs
- Children and youth involved in child welfare
- Children and youth with intellectual or developmental disabilities who also qualify for another ECM Population of Focus
- Children and youth who are pregnant and postpartum at risk for adverse perinatal outcomes and who also qualify for another ECM Population of Focus
In January 2024, ECM eligibility will expand to include the following Populations of Focus:
- Individuals (adults and children) transitioning from incarceration
- Pregnant and postpartum individuals at risk for adverse perinatal outcomes who are subject to racial and ethnic disparities
Additional information about ECM eligibility criteria is available in the DHCS ECM Policy Guide. Visit ECM and Community Supports to learn more.
How can I refer an SFHP member to ECM?
If you believe your patient would benefit from our services, either you or the patient can call our intake line at 1(415) 615-4515 weekdays from 8:30am to 5:00pm. Or email a completed ECM Referral Form to SFHP’s Care Management intake team at email@example.com to evaluate eligibility.
If you have additional questions about ECM, please contact SFHP at CalAIMECMILOS@sfhp.org.
Who provides ECM Services?
Please see the SFHP Medi-Cal Provider Directory to identify ECM providers currently contracted with SFHP.
SFHP will continue to collaborate with community providers to onboard additional ECM providers. Please contact SFHP’s Provider Relations Department at 1(415) 547-7818 ext. 7084 or email Provider Relations if you have any questions.
Description: A 2-part training that overviews the ECM core services and how to work with the populations who are eligible for ECM.
Person-Centered Care Planning Training
Description: An overview of how to conduct person-centered care planning, and how to apply it when working with populations who are eligible for ECM and LTSS.
January 2023 Populations of Focus
Description: This training overviews best practices for working with the two populations of focus that went live in January 2023 – nursing facility residents who could transition to the community and adults at risk for long-term care institutionalization.