What is Enhanced Care Management?

The Medi-Cal services landscape is evolving quickly, and you might have heard a lot about CalAIM Enhanced Care Management (ECM) recently. If you're wondering, "What is Enhanced Care Management, and how does it affect my organization?" Exym is here to help. We’ll guide you through the insights you need to understand the future of Medi-Cal services. Plus, don't miss the quick checklist at the end of our blog to see if you're ready to implement ECM.

The California Department of Health Care Services (DHCS) states that Enhanced Care Management is a Medi-Cal benefit available statewide to select members with complex needs. These members typically have several health conditions encompassing physical, behavioral, and social needs. 

When members have complex needs, they often need to navigate multiple delivery systems to access their care. Care delivery may include primary and specialty care, dental services, mental health care, substance use disorder treatment, and long-term services and supports. This can be challenging for those lacking adequate resources and support like housing, transportation, or recovery services.

CalAIM's Enhanced Care Management (ECM) program addresses members’ needs by offering a whole-person, interdisciplinary approach to care management through a dedicated lead care manager. The lead care manager oversees and coordinates all aspects of a member's health and health-related services. By streamlining care coordination, Enhanced Care Management ensures members receive the appropriate care at the right time and in the most suitable setting, providing a holistic approach extending beyond traditional medical facilities.

Enhanced Care Management addresses both the clinical and non-clinical requirements of Medi-Cal’s highest-need members by establishing trusting relationships and providing intensive, comprehensive coordination of services. Lead care managers provide community-based, person-centered, high-touch care to meet members wherever they are—whether on the street, in a shelter, at a doctor’s office, or at home.

Enhanced Care Management is also available to specific groups of Medi-Cal members, called “Populations of Focus.” These populations include:

• Adults, unaccompanied youth and children, and families experiencing homelessness
• Adults, youth, and children who are at risk for avoidable hospital or emergency department care
• Adults, youth, and children with serious mental health and/or substance use disorder needs
• Adults living in the community and at risk for long-term care institutionalization
• Adult nursing facility residents transitioning to the community
• Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model with additional needs beyond their CCS condition(s)
• Children and youth involved in child welfare (foster care)
• Adults and youth who are transitioning from incarceration. 
• Pregnant and postpartum individuals; birth equity population of focus 

Overall, ECM offers whole-person care management to the highest-need, high-cost Medi-Cal Managed Care Members, with the overarching goals of: 

• Improving care coordination
• Integrating services
• Facilitating community resources
• Addressing social determinants of health
• Improving health outcomes and
• Decreasing inappropriate utilization and duplication of services

The CalAIM ECM Policy Guide highlights that DHCS has long recognized the growing need for care management and coordination as clinical and social complexities increase. In fact, for the last several years, DHCS has been working to develop a more comprehensive approach to care management and coordination within Medi-Cal. Enhanced Care Management takes over where other programs have left off, closing the continuum of care and becoming the new standard for California.

The Role of CalAIM Community Supports in Enhanced Care Management

CalAIM Community Supports are services that help address members’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care. They are available to those in Enhanced Care Management and eligible Medi-Cal members regardless of whether they qualify for ECM services. Community Supports include access to healthy foods or safe housing, which can significantly aid in recovery from illness and access to care. Community Supports focus on:

• Support to secure and maintain housing
• Access to medically tailored meals to support short term recovery 
• A variety of other community-based services.

CalAIM ECM is Part of Medi-Cal’s Broader Transformation

Both CalAIM ECM and Community Supports are critical to the transformation that Medi-Cal is currently undergoing. As Medi-Cal transitions through the CalAIM Initiative, the focus of care is shifting towards:

• Breaking down traditional barriers of healthcare; extending care from hospitals and offices and out into communities 
• Introducing better ways to coordinate care, and
• Providing high-need members with in-person care management where they live

With CalAIM Enhanced Care Management, members gain access to improved services that provide well-rounded care beyond the doctor's office or hospital, addressing their physical and mental health needs. These changes are part of a larger effort to transform Medi-Cal into a more coordinated, person-centered, and equitable health system that effectively serves all Californians.

How Enhanced Care Management Works: A Complex Care Case Study

DHCS features a case study in their FAQ sheet that shows providers how ECM might operate for a hypothetical Medi-Cal member named Frank. In the case study, we learn that Frank has struggled with an opioid addiction and has been living on the streets of San Francisco for the past four years. Here are some additional details regarding Frank’s care: 

• He visited the emergency department seven times in the last two years due to overdoses
• He returned to living on the street after brief stays in shelters 
• Frank contracted COVID-19 in 2020 and continued to experience long-term symptoms 

In this scenario, Frank was referred to Enhanced Care Management by the emergency department due to his substance use disorder. Frank was then connected with a lead care manager to discuss his needs. They decided to meet regularly at a community food bank and collaboratively devised an action plan.

The plan was for Frank to see his mental health provider, get his medication adjusted, and follow up with his primary care doctor. The lead care manager also connected Frank with a local Community Supports provider to help him secure housing that would be safe and supportive during his recovery process.

Positive Impacts of Enhanced Care Management

Enhanced Care Management is vital to Medi-Cal’s transformation, ensuring Californians get the care they need to live healthier lives. ECM breaks down the traditional walls of health care to extend care into members’ communities, introduces better ways to coordinate care, and improves Medi-Cal services for members with complex needs. By making it easier for high-need members to access in-person care where they live, ECM creates a more coordinated, person-centered, and equitable health system for Medi-Cal members.

Are You Prepared for CalAIM ECM?

Enhanced Care Management requires strong technological capabilities for documentation and billing, collaboration with other providers, and the sharing of electronic records. Is your organization prepared for CalAIM ECM?

Exym is a comprehensive EHR software solution designed specifically for behavioral health agencies. Trusted for 20+ years, our intuitive and customizable software empowers providers to improve client outcomes, manage revenue cycles, and increase agency efficiency. Exym allows you to spend more time on what matters most- the clients in your care.

If you need strong EHR software from a company with long-standing, trusted partnerships in California, we’re here to help! We understand California’s unique billing requirements, have navigated Medi-Cal and CalAIM reforms, and are ready to support your agency in whatever comes next.

Book a demo today to talk to our Exym experts!