Letitia is a 40-year-old female with Type-2 diabetes and Asthma living in suburbs with her two small children. She is eligible for Medicaid due to her low income and is currently enrolled in a managed care plan. A few months ago, she injured her back and has trouble driving to work and working full-time. She has uncontrolled diabetes and taking medications and insulin to manage it, and she has been to ER 3 times in the last 6 months. She is facing difficult life and health circumstances and is often not able to refill her diabetes medications or take care of her asthma. Her glucose control is highly variable as traveling to the doctor’s office is challenging, limiting her access to routine monitoring. Her grocery money runs out well before month’s end and her food choices are limited to non-perishables bulk items.
Letitia can benefit from enhanced care management (ECM) and community supports (CS).
What is Enhanced Care Management (ECM)?
ECM provides a whole-person approach to care that addresses the clinical and non-clinical needs of people with complex health issues. The main goal of enhanced care management is to achieve better health and cost outcomes by improving care coordination, integrating medical and behavioral services, and facilitating community resources to address social determinants of health.
ECM is a new and required benefit for all managed care Medicaid plans in California.
Who offers Enhanced Care Management (ECM)?
At this time, enhanced care management (ECM) is offered to Medi-Cal members who are enrolled with managed care plans in California. Managed care plans are responsible for the care of more than 90 percent of Medi-Cal enrollees.
ECM comes from a new Medi-Cal initiative called California Advancing and Innovating Medi-Cal, also called CalAIM. CalAIM focuses on improving health equity and quality of care and well-being for California Medicaid (Medi-Cal) members by enhancing population health; expanding access to coordinated, equitable, whole-person care; and addressing health-related social needs.
CalAIM is taking a population health management (PHM) approach to address the needs of all members across the continuum of care. Under PHM, CalAIM expects the managed care plans (MCP) to implement a whole-system, patient-centered strategy that focuses on wellness and prevention, includes assessments of each member’s health risks and health-related social needs, and provides care management and care coordination across all systems and settings.
CalAIM is viewing ECM benefit as one of the care management programs that managed Medicaid organizations should offer to their enrolled populations. This benefit is designed primarily for members at the highest risk level.
Who provides Enhanced Care Management (ECM) Services?
ECM is offered primarily through community providers with experience and expertise in providing intensive, in-person care management services in the geographical areas where members and their families live. The managed care plans are not allowed to provide ECM services, with some exceptions (when they are not able to find and contract with ECM providers). In general, the managed care plans are required to contract with ECM providers such as Federally Qualified Health Centers (FQHCs), Primary Care Providers (PCPs), Community Health Centers, Substance use disorder (SUD) treatment providers, and others.
What services are included in Enhanced Care Management benefits?
First and foremost, if a member qualifies for ECM, their current benefits will not change. They can keep their doctors and providers. They get additional benefits on top of the medical services they are receiving.
At a high level, the additional services include:
- Finding doctors and getting an appointment for physical, mental, and substance use health needs
- Keep all of the member’s providers fully informed
- Set up transportation to their doctor visits
- Get follow-up services after the member leaves the hospital
- Manage all of the member’s medications
- Get help connecting to local resources such as food or other social services
All ECM services are provided at no cost to the member, and they can stop ECM at any time.
How does Enhanced Care Management (ECM) work?
Managed care plans are responsible for identifying (or accepting referrals for) enrollees eligible for ECM. After identification, they assign every member (authorized for ECM) to an ECM provider. Each member is assigned a lead care manager by the ECM provider. The lead care manager serves as the point of contact for the member. The lead care manager is responsible for creating a comprehensive care management plan. They talk with the member’s doctors, mental health providers, specialists, pharmacists, case managers, social services providers, and others. They make sure everyone works together to get each member the care they need. The lead care manager can also help the member find and apply for other services in the community.
Who is on the Enhanced Care Management (ECM) care team:
- Lead Care Manager
- Behavioral Health Care Manager
- Care Coordinator
- Community Health Worker
Who is eligible for Enhanced Care Management (ECM) benefit?
To be eligible for Enhanced Care Management (ECM) benefit, the member must be enrolled in a Medi-Cal managed care health plan and meet certain eligibility requirements. Unfortunately, these eligibility requirements can be quite complex to understand. At a high level, a member can be eligible for enhanced care management, if they satisfy one or more of the following criteria –
- They are experiencing homelessness
- They have at least one complex physical, behavioral, or developmental need
- They are considered a high utilizer with frequent ER and hospitalization visits
- They are transitioning from incarceration
- They are an adult with Serious Mental Illness (SMI) or Substance Use Disorder (SUD)
There are some exceptions (like PACE, SNP, and HOSPICE) that are applied on top of ECM eligibility rules. The current eligibility criteria will be expanded starting Jan 1, 2023, to include Adults at Risk for Institutionalization & Eligible for Long-Term Care, Nursing Home Residents Transitioning to the Community, and Children and Youth High Utilizers or With Serious Emotional Disturbance (SED).
Duals with managed care Medi-Cal and Medicare FFS are ECM eligible, but Cal MediConnect duals (or duals enrolled in other Medicare Advantage plans) are not.
Who is funding the ECM benefit?
California Department of Health Care Services (DHCS). DHCS seeks to advance ECM and Community Supports initiatives with significant incentives for managed care plans to invest in the capacity of community-based organizations and other providers. In addition, ECM and Community Supports providers are able to access funding and technical assistance directly through the Providing Access and Transforming Health (PATH) program. The PATH initiative provides funding for providers, community-based organizations, and other entities to expand their capacity to better serve the members.
Why is DHCS funding ECM benefits?
Over 50% of Medi-Cal spending is attributable to the 5 percent of members with the highest-cost needs. These members typically have several complex health conditions involving physical, behavioral, and social needs. They often need to engage with multiple delivery systems such as primary and specialty care, dental, behavioral health, and support for substance use disorder.
DHCS believes that a comprehensive, community-based coordinated care model that is focused on the whole health of these highest-cost members can help them achieve better health and cost outcomes.
A few years ago, DHCS introduced community-based care management with promising results in many counties through the Health Homes Program and Whole Person Care Pilots. CalAIM is DHCS’s first statewide effort to address complex care management.
How is ECM different from other managed care benefits?
ECM benefit is targeted to Medi-Cal members with the highest needs. ECM is provided by community-based providers rather than health plan staff. This is to ensure that care management is provided where the member lives, seeks care and prefers to access services. It is designed to be local, high-touch, with in-person contact.
In addition, ECM takes a “whole person” approach. The scope of ECM services includes medical, behavioral, social, and long-term services and supports (LTSS) needs of members.
How does ECM compare to HHP?
The ECM model of care provides the highest level of care management to clinically and socially complex members. There are a lot of similarities between ECM and HHP – with similar core services, except for outreach and engagement which is added as a core service in ECM. Housing transition service from HHP is moved out to the community supports program.
ECM benefits have expanded eligibility criteria to cover additional populations of focus.
What are community supports (CS)?
Unlike Enhanced Care Management, Community Supports are not formal Medi-Cal benefits and are optional for plans to provide. Community Supports are a menu of services that can comprehensively address the needs of members with the most complex health issues, including conditions caused or exacerbated by lack of food, housing, or other social drivers of health. These services include housing deposits, housing tenancy services, respite services, personal care and homemaker services, medically tailored meals, transportation, etc.
At this time, the most common community support services include Medically Supportive Food and Medically Tailored Meals, Asthma Remediation, Housing Transition Navigation Services, and Housing Tenancy and Sustaining Services.
Who provides the community supports?
Community Supports are offered by Medi-Cal managed care plans as cost-effective alternatives to traditional medical services or settings. Plans have the flexibility to choose whether to offer a Community Supports service — and when and where and to whom. Plans may elect to provide new Community Supports every six months, can remove services annually, and may offer a different set of services for each county in which they operate.
Community support services are provided by community support providers. Community Supports providers are contracted providers of the Department of Health Care Services (DHCS). CS providers are organizations with experience and expertise providing one or more of the CS to individuals with complex physical, behavioral, developmental, and social needs.
Why is DHCS funding community supports for social drivers of health?
There are several reasons for DHCS to fund community supports. Medi-Cal members with complex health needs and unmet social needs are at high risk of hospitalization, institutionalization, and other higher-cost services. Given the large homeless population in California, DHCS is concerned about the higher rates of diabetes, hypertension, HIV, and mortality among homeless people, which is resulting in longer hospital stays and higher readmission rates than the general public.
Health equity and food insecurity are also big issues for DHCS. More than 65 percent of Medi-Cal enrollees are from communities of color, and about 20% of Californians experience food insecurity. By addressing social drivers of health, DHCS is working towards advancing health equity and helping people with high health care and social needs.
Who is eligible for community support services?
The eligibility criteria vary for each community supports service. The managed care plans (MCPs) are required to validate the member’s eligibility for community supports based on approved Community
Supports service definitions and eligibility criteria.
What type of community supports are available?
For members with food insecurity and limited access to healthy food, meal benefits can be beneficial. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. In general, these benefits are provided to members for a short duration, after an event, for example when they leave the hospital or a skilled nursing facility. Members are most vulnerable to readmission at that time, and meals delivered to home can be very useful to prevent readmission. Medically-tailored meals are provided to the member at home that meets the unique dietary needs of those with chronic diseases.
In addition, the members may also get help with case management and nutrition support to help them stay healthy.
Housing Transition Navigation Services
Housing transition navigation services can help members find and apply for housing. They can also get help with setting up their rental process. The service includes searching for housing and presenting options to the eligible member. The service provider also assists in securing housing, including the completion of housing applications and securing required documentation (e.g., Social Security card, birth certificate, prior
rental history). The service providers should also ensure that the living environment is safe and ready for move-in. This may include identifying, and coordinating, environmental modifications to install necessary accommodations for accessibility.
Housing Deposits can help the member get one-time funding for housing and establish a basic household. This may include security deposits, set-up fees and deposits for utilities, the first month or last month’s rent, one-time cleaning service, payments for goods such as an air conditioner or heater, and other medically necessary adaptive aids and services. The housing deposit services do not include the provision of room and board or payment of ongoing rental costs beyond the first and last month’s coverage.
Housing Tenancy and Sustaining Services
Housing tenancy and sustaining services can help the member maintain a safe and stable tenancy once they get housing. They can also get training in independent living and life skills like budgeting and financial literacy. This service includes advocacy and linkage with community resources to prevent eviction when housing is or may potentially become jeopardized.
Recuperative care, also referred to as medical respite care, is short-term residential care for individuals who no longer require hospitalization, but still, need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable living environment. Recuperative Care is primarily used for those individuals who are experiencing homelessness and allows members to continue their recovery and post-discharge treatment with temporary housing, medical care, and other services such as case management, self-management support, and help with housing.
Respite services are provided to caregivers of members who require supervision. The services are provided on a short-term basis to support the needs of people who care for the patients. These services can be provided by the hour on an episodic basis in the participant’s home or another location of their choice. Respite services are made available when it is useful and necessary to maintain the member in their own home and to preempt caregiver burnout to avoid institutional services for which the Medi-Cal managed care plan is responsible.
Short-Term Post-Hospitalization Housing
Short-Term post-hospitalization housing provides residential and supportive services to members who have high medical or behavioral health needs. Through this housing service, members can continue their recovery right after leaving the inpatient hospital, residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care.
Members must be offered housing transition navigation supports to prepare them for the transition from this setting. These services should include a housing assessment and the development of an individualized housing support plan to identify preferences and barriers related to successful housing tenancy after this service.
Sobering Centers are places for people who are found to be publicly intoxicated due to alcohol or drugs. They provide an alternative space for people who would otherwise have to go to the emergency department or jail. Sobering centers provide a safe, supportive environment to become sober and receive referrals for services. This service is mainly for people who are homeless or living in unstable situations.
Sobering centers provide services such as medical triage, lab testing, a temporary bed, rehydration and food service, treatment for nausea, wound and dressing changes, shower and laundry facilities, substance use education and counseling, navigation and warm hand-offs for additional substance use services or other necessary health care services.
Asthma remediation includes changes to the home environment that are necessary to enable the individual to avoid acute asthma episodes that could result in the need for emergency services and hospitalization. The services are available in a home that is owned, rented, leased or occupied by the individual or their caregiver.
Examples of asthma remediation include Allergen-impermeable mattress and pillow dust-covers, HEPA-filtered vacuums, de-humidifiers, air filters, ventilation improvements, and other interventions identified to be medically appropriate and cost-effective. An order from the member’s current healthcare provider is needed with a written evaluation that the service will likely avoid asthma-related hospitalizations, emergency department visits, or other high-cost services.
Personal Care and Homemaker Services
Personal Care Services and Homemaker Services are provided for individuals who need assistance with Activities of Daily Living (ADL) such as bathing, dressing, toileting, ambulation, or feeding. Personal Care Services can also include assistance with Instrumental Activities of Daily Living (IADL) such as meal preparation, grocery shopping, and money management.
Services provided through the In-Home Support Services (In-Home Supportive Services) program include housecleaning, meal preparation, laundry, grocery shopping, personal care services (such as bowel and bladder care, bathing, grooming, and paramedical services), accompaniment to medical appointments and protective supervision for the mentally impaired.
These are the early days for ECM and Community Supports. The programs were launched in a relatively short period of time and it is taking some time for the health plans and community-based organizations to figure out everything they need to be successful.
The success of these programs is dependent upon the close collaboration between managed care plans and community providers. Most of these challenges are due to the ‘newness’ of their relationship and lack of understanding of each other’s needs.
Contracting and working with Community-Based Organizations (CBOs)
Health plans are finding it difficult to identify the right CBOs for specific community supports. Since managed care plans are paid per beneficiary, they are looking for a similar type of risk arrangement with providers. However, different CBOs are at different phases of maturity when it comes to accepting value-based payments. This is why a large percentage of CBOs are still in the exploration stage. Traditionally CBOs have contracted with counties and working with health plans is a new concept for them. Alignment with health plans’ goals requires a significant change in culture and infrastructure for CBOs. They need help and support to learn and implement the competencies required to be successful in this new world.
Variation between health plans
Because Community Supports are optional service, plans have made different decisions locally, leading to
variation across the state. These variations exist between counties for the same health plan. There is also significant variation in the referral process, billing, and invoicing. Each plan has unique policies, processes, portals, tools, and delegation arrangements with other plans, and navigating these differences is time-intensive and particularly challenging for small organizations with limited staff and resources. This is causing a lot of confusion for community providers, who often have to work with multiple health plans.
Complex eligibility criteria
The eligibility criteria for ECM and community supports are quite complex. Members with complex needs often need multiple services and it is often hard to know who is eligible for what services at a given point in time. On top of eligibility checks, the health plans have to check for duplicative programs. Health plans don’t always have access to all duplicative programs. If they learn about it after the ECM is already started, the member is asked to make a choice of either ECM or the other program, which can be very time and resource-consuming.
Although DHCS has defined target populations of focus, it is requiring plans to develop policies and procedures for ECM eligibility, and notifying members and families of determinations. For Community Supports, DHCS has defined eligibility criteria, but health plans are responsible for establishing their own policies and procedures describing how the service will be provided to eligible enrollees (e.g., expected duration and frequency of service) and can impose more narrowly defined eligibility criteria. These inconsistent processes and timeframes are complex to understand for all stakeholders.
Outreach and enrollment challenges
There are a lot of community support benefits and it can be overwhelming for the CBOs and members to understand the benefits and navigate them. CBOs are finding that about 1/4th of the members assigned to them have incorrect information which leads to a significant waste of time in outreach. In addition, difficulties locating and engaging members who could benefit from ECM have also presented cash flow issues for ECM providers – when fewer-than-expected members were found, engaged, and enrolled, and payment was contingent on enrollment.
Up-front costs and challenges
Community Supports and ECM providers often need significant up-front investments at their own expense to meet health plans’ readiness, vetting, and credentialing requirements, and to remain competitive and responsive. The plans’ processes add a significant administrative burden for the CBOs. A number of providers have hired additional staff to meet capacity criteria, which is putting more financial pressure on them.
Low referral volume and utilization
The number of referrals is paltry at this time. Some plans have achieved their internal; targets, but actual referrals for most CBOs have come below expectations. In many counties, there are no referrals, which is leading to frustration.
The utilization of community support remains low. There are many counties where the contracts are not finished or the referral and support processes have not been finalized yet.
Strategies for promoting greater adoption of ECM and Community Supports benefits
There is no denying that if done well, Enhanced Care Management (ECM) and Community Supports have the potential to improve the quality of care and outcomes for vulnerable and at-risk members. To make them work, plans have to work closely with ECM and community supports providers that have close connections with eligible members.
While more experimentation is needed, there are some strategies that can be adopted by health plans to create the right foundation and building blocks for sustainable advantage.
Operational support for local providers
As new CBOs become partners with health plans, they have a need to build critical infrastructure and capacity. CBOs need more assistance and support in the implementation of these programs. Having more and easier access to implementation toolkits that take into account their use cases will be useful. Giving providers access to care management platforms, billing systems, referral systems, reporting capabilities will be very helpful.
Learn more about integrating health and social services for enhanced care management
Most community-based organizations lack the resources to make sense of different credentialing, vetting, claims submission portals, authorization processes, and referral platforms – offered by different health plans. Having standardized workflows across different health plans, especially in the same county, will go a long way in reducing complexity.
Understanding each plan’s authorization criteria is essential for seamless transitions of care, and appropriate, timely referrals. CBOs lack the resources and patience to understand each plan’s authorization criteria for different services. Having auto-approvals for a limited time for commonly used services will be useful to deliver care and support the member’s social needs faster.
Flexible payment models
More flexibility in payment models will be useful to attract and retain more CBOs. Not every CBO is ready to accept value-based payments. Not all benefits are suitable to be paid on a pmpm basis.
Timely data sharing
Accurate data can help health plans more intimately understand community needs at the local level, These insights can be used to design appropriate community supports, not only about the services, and who can benefit from it – but also who are the right provider partners for each service. Health plans and CBOs should collaborate on the data systems to exchange information to collect and integrate more data about each member to identify needs at an individual level, community level and the county level.
Learn more about leveraging digital tools for enhanced care management (ECM)
Technology platform to manage and administer ECM and Community Supports benefits
At its core, ECM and Community Supports benefits are personalized benefits. The legacy technology infrastructure used by health plans was not designed to offer tailored personalized benefits. Health plans need a strong technology foundation to design personalized benefits that improve the quality of life, functional independence, and experience of care for members, and substantially reduce avoidable spending.
Data and analytics platform to understand the needs of member subpopulations
Understanding the unique needs of member subpopulations is key to designing personalized whole-health benefits. To achieve this goal, health plans should invest in a strong data and analytics platform that can unify physical, behavioral, and social data for each member, and provide them insights into what each population subsegment wants and needs.
The health data platform can integrate claims, and clinical and social data from disparate sources, and normalize it to create a single source of truth for each member. This unified longitudinal record of each member when run through predictive analytics helps the health plans build highly targeted member segments with actionable, AI-powered insights into member needs.
In addition to data ingestion, transformation, unification, and analysis, the health data platform can share the members’ unified profiles with other systems (such as community providers) who can find it extremely useful. Knowing what physician was seen by the member, what medications were picked from what pharmacy, and when did the member last used the ER can be great data points for community-based organizations when they are trying to engage the hard-to-engage member subpopulations.
Customizable benefit designer tools to design the right benefits
Designing personalized community supports benefits is hard. Health plans have to juggle multiple options across different benefits due to limited funding, evidence, and utilization data. This requires flexibility in designing benefits to experiment and learn.
Sprite Health’s dynamic benefits solution helps managed care plans to easily design personalized community supports benefits with a flexible architecture. The product management teams can customize each benefit by specific services, limits, choice of providers as well as max benefit amounts.
Helping members understand, navigate and utilize their benefits
Healthcare navigation plays a crucial role in helping people get the right support, at the right time, across an extensive set of complex health needs. Successful healthcare navigation works to alleviate members’ physical, geographical, and emotional struggles and adequately address their financial needs.
Sprite’s Health navigation solution provides health plans the tools to meet members where they are while empowering them with information and guidance that will impact their health and wellness. Whether they need to understand how their benefits work, review their claims, manage their spending, find a provider, or submit a claim – the health navigation solution brings everything together into one connected experience.
Whole-person digital care management that integrates community supports with medical care
Disjointed care can result in increased costs and a frustrating member experience. Most community supports are not currently integrated with medical care. Care managers often don’t know what benefits are available to what members and are not able to incorporate the resources for social needs in their care plans. Also, many members who need one benefit also need other services. For example, expectant mothers need consistent appointments, transportation to these appointments, and nutrition geared toward mothers and babies. Calling, and coordinating different services from different dashboards, and phone lines are causing a lot of administrative workload for the care coordination teams.
Sprite Health’s digital care management solution provides a single resource to care teams to proactively identify and manage the whole picture for any one individual. It links care teams with medical services, behavioral health, community resources, transportation services, social and home settings, and cultural and religious centers. This way care teams can anticipate, care for, and stay with the member throughout their journey to better health.
To successfully implement ECM and community supports benefits, managed care plans and community-based organizations (CBOs) must undergo a major transformation to succeed. This transformation is not limited just to changes within their organization but also extends to learning new ways to work with each other. Connect with us to learn how our end-to-end unified solution can help you successfully implement and effectively manage your Community Supports and ECM offerings.