Over 50% of the annual Medicaid spending is attributed to about 5-10% of members. These high-cost, high-need members typically have several complex health conditions with significant physical, behavioral, and social needs. A large percentage of these members experience health disparities and due to health equity gaps, they are at significant risk for hospitalization, institutionalization, and other higher-cost services. Due to a lack of care advocacy and coordination support, most of them end up in hospitals with longer stays and have high readmission rates.

Enhanced care management (ECM) is a new benefit from Medi-Cal. ECM is designed to support the holistic needs of high-risk, high-need members, by taking a whole-person approach to care that addresses the clinical and non-clinical circumstances. This benefit is designed to complement primary care to address systemic issues to achieve better health outcomes and decrease inappropriate utilization – by improving access to community support for social drivers of health and coordination of care with medical, behavioral, and social support providers.

To deliver ECM services, the providers must deliver several core services to the eligible population including outreach, care planning, care coordination, transitional care, and referrals to community and social support services. Each enrolled member is assigned a lead care manager who is their primary point of contact. The lead care manager supports the member in finding doctors, scheduling appointments, managing medications, arranging transportation, finding and referring to community-based services, and setting up follow-up care after the hospital. They are also expected to keep all stakeholders up-to-date about the member’s needs and care.

Partners (community housing, pharmacies, food banks, mental health providers) directory for enhanced care management

ECM services can be very beneficial for high-cost, high-need members. In addition to reducing downstream costs for managed care organizations, ECM services can significantly increase revenue for participating ECM providers with the per patient per month paid for every engaged member. However, doing it well requires significant effort in operations, compliance, billing, and reporting. In absence of a robust technology backbone, this great opportunity can turn into a high-cost center for ECM providers and community support centers. Organizations participating in ECM services should consider exploring a digital care management solution to implement a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of high-need high-cost members through systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch and person-centered.

The digital care management solution can provide the right technology support for the providers to quickly launch ECM services. It provides the following tools to help your care teams break down the traditional walls of health care and enable them to extend care beyond hospitals into communities.

Data integration

There are strict requirements on the ECM providers and community-based organizations to exchange information about members with managed care plans. A digital care management solution leverages a data platform to integrate data from disparate sources across the continuum of care to create a unified longitudinal member record. With the unified patient record, you get a trusted 360-degree view of the people you serve to accelerate the success of your care management initiatives and fully understand your patients’ preferences, risks, and needs from the beginning and throughout their care journey. The data platform can ingest data in multiple formats from MCPs and provide them the member outreach and engagement information as well as referral files in standardized formats.

Patient outreach for enhanced care management

Member outreach

The digital care management solution provides you the capabilities to reach out to eligible members via phone calls, emails, or text. Each interaction is tracked in the system and can be reported back to the MCPs. It provides the tools to create content in multiple categories and languages to improve your enrollment efforts in harder-to-reach communities (e.g., Hispanics, African Americans, immigrants, the LGBT community, young adults, and veterans). Predefined email, text templates make your job easy and amplify your reach to many more members.

Partners directory

By using the digital care management platform, ECM providers and community-based organizations can bring multiple partners into an integrated experience—from community housing, pharmacies, food banks, mental health providers, and numerous others who are all currently working in silos.

This helps reduce friction for the community members who have typically avoided receiving services due to fear or inability to find the right support provider. The system makes it super easy to find care, schedule appointments, message, and connect with members and support partners.

Personalized care plan

The digital care management solution empowers care managers to create a whole-person care plan that is tailored to the member’s specific needs and diagnosis, as well as being utilized as a guide, teaching tool, or road map for continuity of care activities. Patients can complete a self-assessment of their health needs, preferences, and goals. The lead care manager and patients can set up meaningful shared goals, set milestones, and track the progression against the goals. The system also enables collaboration between all stakeholders to keep everyone in the loop on the patient’s progression against goals.

Smart outbound referrals to avoid leakage and maintain care continuity

Closed loop referrals

When it comes to supporting enhanced care initiatives, successful referrals are vital. The digital care management solution enables you to take a proactive approach that matches patients to the care they need, reduces patient leakage, and improves care coordination. The solution guides patients to the most appropriate in-network providers and community-based organizations through a configurable matching algorithm that considers factors like patient needs, specialty, proximity to the patient, etc. The solution further supports appointment attendance with patient engagement methods such as appointment reminders.

In short, to deliver outstanding enhanced care management services, you can benefit from a digital care management solution. It provides you with the technology infrastructure you need to automate clinical operations, improve the quality of life for your care staff, and improve health equity for your patients.