Enhanced Care Management (ECM) Provider Information

The Alliance will authorize referrals for the ECM program. Ideally, ECM providers will engage with eligible community members in person in a culturally and linguistically appropriate way to inspire trust and build relationships. The Alliance and ECM providers will collaborate to provide support for eligible members whether they accept or decline ECM services.

ECM providers will develop a person-centered care management plan, including input from the member and their clinical team. This care plan should:

• Identify clinical and non-clinical resources.
• Include person-centered strengths, risks, needs and goals.
• Prioritize physical and developmental health, mental health, dementia, substance use disorder (SUD), long-term services and supports (LTSS), oral health, palliative care, necessary community-based and social services, and housing.

The plan should be reassessed and updated as the person’s needs evolve.

ECM providers organize activities per a care management plan by partnering with a multi-disciplinary team of care providers.

This includes ensuring that:

• The participant is connected with their primary doctor for care management assistance.
• Care is continuous and integrated among all service providers.

Care coordination includes:

• Coordination for medication review and/or reconciliation.
• Scheduling appointments.
• Providing appointment reminders.
• Coordinating transportation.
• Accompaniment to critical appointments.
• Identifying and helping address other barriers to care, including supporting member communication with providers.

Health promotion involves encouraging and supporting ECM members to make lifestyle choices that support their health and wellness. This could include:

• Coaching.
• Strengthening a member’s ability to identify and access resources.
• Using practices such as motivational interviewing to support participants in managing their own care.

Transitional care services aim to decrease care facility readmissions. ECM providers partner with care facilities to support participants in transferring levels of care. This involves support in areas such as medications and follow-up.

Transitional care services include:

• Having a discharge plan.
• Assisting members with all associated logistics (such as transportation and medication reconciliation).
• Helping the member understand the plan.

For members already enrolled in ECM at the time of a care transition, the ECM lead care manager serves as the member’s TCS care manager and single point of contact for every care transition. Responsibilities include:

• Successfully connecting with the member within 7 calendar days of discharge.
• Reviewing discharge information and addressing member questions.
• Ensuring post-discharge medication reconciliation is completed.
• Ensuring follow-up with medical provider occurs within 7 days of discharge.
• Continuing TCS until the member is connected to all needed services and supports and for at least 30 days after discharge.

For members enrolled in ECM who meet criteria for high-intensity pregnancy and postpartum TCS, the ECM lead care manager serves as the member’s TCS care manager and single point of contact throughout the transition. The ECM lead care manager is responsible for coordinating TCS and ensuring completion of the DHCS TCS Birthing Supports Checklist and identified services and supports.

This includes:

• Completing post-discharge or post-pregnancy outreach with successful connection to the member within 7 calendar days of discharge, or within 7 calendar days following the end of pregnancy when there was no admission.
• Ensuring completion of the DHCS TCS Birthing Supports Checklist throughout the pregnancy and postpartum periods, including coordination of needed medical, behavioral health, and whole-person services and supports.
• Using referrals and warm handoffs, when appropriate, to qualified care team members when an identified service or activity is outside the scope or role of the TCS care manager or care coordination entity.
• Coordinating recommended follow-up care and identified supports, including postpartum, pediatric, primary care, specialty, behavioral health, transportation, nutrition, lactation, doula, home visiting, and other services based on the member’s needs and preferences.
• Continuing high-intensity pregnancy and postpartum TCS until the member’s needs are met. Services should end no sooner than 60 days following the end of pregnancy, or 30 days after discharge for a non-delivery admission, whichever is later. Required follow-up must also be completed.

Member and family supports refer to communication with an identified support person regarding the member’s conditions and overall goals. The ECM provider will ensure that the appropriate authorizations are in place.

Additionally, the ECM provider is responsible for the following aspects of involving the member and their family and/or support people:

• Acting as a primary point of contact.
• Identifying support needed.
• Providing education and a care management plan.

The member should be actively involved in the process and the care plan that is shared with the support person.

Coordination of and referral to community and social support services involves determining appropriate services to meet the needs of members receiving ECM. This is to ensure that any present or emerging social factors can be identified and properly addressed.

Coordination of and referral to community and social support services could include, but is not limited to:

• Determining appropriate services to meet the needs of members, including services that address social determinants of health (including housing) and services offered by Contractor as Community Supports.
• Coordinating and referring members to available community resources and following up with members (and/or their parent, caregiver or guardian) to ensure services were rendered (i.e., “closed loop referrals”).