ECM (enhanced care management) and Community Supports (CS) benefits are targeted to high-cost, high-need members who will gain the most from from the whole-person, interdisciplinary, community-based care management services. It is the responsibility of managed care organizations (MCOs) to identify the right members based on DHCS defined eligibility criteria and connect them to the right programs. This can be a complex undertaking for many reasons. Incomplete data, lack of integration between different data systems, complex eligibility criteria and the challenges to collaborate with multiple community providers are just a few.

ECM process and data flow

The first of many things in ECM is for MCO to identify members based on DHCS’s specific eligibility criteria for ‘target populations’ that include, but are not limited to: high utilizers (top 1–5%) of care; individuals at risk for institutionalization, individuals with frequent hospital or emergency room (ER) admissions, nursing facility residents who want to transition to the community, individuals transitioning from incarceration and individuals suffering from chronic homelessness or who are at risk of becoming homeless.

Enhanced Care Management (ECM) process and data flow

After the members are identified, the managed care organizations have to identify the providers each member has engaged with and determine the most appropriate provider for ECM assignment based on that member’s physical, behavioral health, and social needs. ECM providers may include primary care providers (PCPs), behavioral health specialists, county behavioral health providers, and community clinics, among others. After assignment is confirmed, the managed care organization forwards the member information to the chosen ECM provider. This information is shared via the member information file (MIF) that contains member demographic and clinical information and ECM benefit status, within the specific time duration.

The ECM providers are required to send the provider return transmission file that includes enrollment information as well as the information about who is leading the care management efforts for each member enrolled in the program. In addition, the providers are also expected to send the initial outreach tracker file. Unlike previous programs, ECM benefit requires reporting of outreach data and the DHCS is paying managed care organizations for these efforts as part of their capitation payment. The initial outreach tracker file ideally should include the new HCPCS codes to report on each outreach effort.

Community providers can also send a referral to the managed care plans for members who they think should be considered for ECM benefit. There are 3 Steps to the screening and referral process:

  1. Complete the Population of Focus screening checklist to confirm member eligibility
  2. Complete exclusionary screening checklist
  3. If determined to be eligible for ECM based on both screening checklists, complete the ECM referral form and send securely to the member’s Health Plan

Streamlining segmentation to enrollment process for ECM and Community Supports

Sprite Health understands resource strain on managed care organizations with the implementation of CalAIM and other DHCS mandates. We provide a health navigation solution that can streamline the process of identification, engagement and coordination of enrollment of members into ECM and Community Supports programs from start to finish.

Member identification in Enhanced Care Management (ECM) and Community Supports (CS)

Member identification

Sprite’s health navigation solution is build on top of our advanced health data platform that aggregates data from multiple sources such as claims, EHRs, labs, images, counties as well as community based organizations (CBOs) to create a 360 degree view of each member. With this data integration, MCOs get a deeper understanding of different member subpopulations (for example members with specific physical and behavioral along with Activity of Daily Living (bathing, eating, dressing, etc.) issues. The longitudinal member records are used by our analytics and AI/ML models to identify members most likely eligible for the appropriate programs. In addition, the member segmentation tools support the target membership criteria provided by the MCOs.

After the members are identified, the solution can help the MCOs identify the right ECM provider (based on custom rules), generate the Member Information File (MIF) and send it to the provider.

Contact and Engagement in Enhanced Care Management (ECM) and Community Supports (CS)

Contact and engagement

Sprite’s health navigation solution provides you (and your community partners) the superpowers to engage complex, high-risk, high-cost members who are typically hardest to reach. The outreach specialists at MCO (and your community partners) can target specific subpopulations (for example members with complex chronic conditions, SMI or SUD issues, and Homeless) with custom outreach campaigns that deliver targeted messages to each member’s preferred channel (mail/text/email etc.). Each outreach effort is tracked in the system to report the total number of both successful and unsuccessful initial outreaches to members using compliant encounter data.

In addition, the outreach teams can easily engage with members to perform intake assessment and/or collect the missing Social Drivers of Health (SDoH) information and coordinate the enrollment of members into care management.

Program enrollment

Sprite’s health navigation solution can help your (or your community partner) teams choose the appropriate pathways to enroll the member in different programs for which the member qualifies. The solution enables teams to obtain and document from each assigned member verbal or written consent for ECM and authorization for data sharing, in accordance with DHCS guidance and Federal, State, and local laws. The solution handles the enrollment of the members from start to finish. This significantly reduces the work required by the member and resources required by the plan.

Connect with us to learn how our end-to-end unified solution can help you streamline the process of identifying, engaging and enrolling the complex, high-risk members that qualify for Enhanced Care Management (ECM), Community Supports, and other federal and state (needs-based) benefit programs.