Enhanced Care Management Explained For Better Patient Care

The transition to value-based care is rapidly changing how healthcare is delivered across the nation.

California, for instance, is resolving the issue of fragmented care for its most vulnerable populations using Medi-Cal’s Enhanced Care Management (ECM). It’s a program perfectly positioned to tackle the social determinants of health by addressing the medical, logistics, and lifestyle side of care management.

In this post, we’ll explore what ECM is, who qualifies for the program, its benefits, and the tools you can use to support it.

What are Enhanced Care Management Programs?

Enhanced Care Management is a Medi-Cal benefit designed to provide a personalized support system for those in the healthcare system who are the highest in need, such as those with multiple chronic conditions, a history of homelessness, or high ER utilization.

As part of Population Health Management, the program is delivered by community-based providers who understand the local landscape well. It aims to coordinate care across the following systems:

• Physical health
• Behavioral health
• Social services (non-clinical needs)

It has the following seven core service components:

• Health promotion
• Outreach and engagement
• Enhanced care coordination
• Member and family support
• Comprehensive transitional care
• Comprehensive assessment and care management plan
• Coordination of and referral to community and social support services

You’ll deliver the program primarily in person to help beneficiaries attain their health goals in the least restrictive setting possible.

Care managers should meet beneficiaries where they seek care or live/stay, including street encampments and homeless shelters.

Key Benefits of Enhanced Care Management

With ECM, California made a bold step towards achieving health equity, as the target populations historically had poor health outcomes.

ECM helps address the underlying factors outside of your clinic or office that, if left unresolved, would cause a patient to cycle in and out of the health system.

The interventions implemented under this system will benefit both you and the patient:

Patient-Related Benefits

Patients benefit from ECM in the following ways:

• Whole-person support: ECM helps address care constraints that standard insurance won’t cover. For instance, linking a diabetic patient facing homelessness with community support systems can help improve outcomes, as it’s hard to maintain a healthy diet without stable housing and meal plans.
• Enhanced accessibility: ECM extends care to patients wherever they are, including underserved environments such as homeless shelters and street encampments.
• Effective coordination: The patient is assigned a lead care manager, making it easy to coordinate all relevant cases across mental health, probation, housing, etc.
• Prevents drop-offs: Follow-up appointments when a patient leaves the hospital or prison ensure smoother care transitions.

Provider-Related Benefits

ECM has the following benefits for healthcare providers:

• Higher patient compliance: ECM helps increase adherence to medication and show-up rates for appointments. For instance, if an ECM manager solves logistical issues like pharmacy pickups and transportation to the hospital, non-compliance rates will drop.
• Efficiency in operations: As a primary caregiver, you often have to deal with the patient’s non-clinical needs. ECM provides a way to refer these issues to equally caring professionals, allowing you to focus on actual medical care.
• Incentive payments: When you run an ECM program, you’ll receive payments per member per month as well as performance-based incentives for high engagement, outcome improvements, etc. You can redeploy the new revenues to enhance patient care across the board.

Who Qualifies for Enhanced Care Management Services?

To qualify for ECM, one must fall under at least one of the “Populations of Focus” below:

• Birth equity population of focus (pregnant or postpartum)
• Persons experiencing homelessness
• Those at risk for avoidable hospital or Emergency Department utilization
• Adults with serious substance use disorder or mental health needs
• People transitioning into the community from incarceration
• Children or youth involved in child welfare (adoption/foster care/family maintenance)
• Adults who are at risk of Long Term Care (LTC) institutionalization
• Adult nursing facility residents moving out of institutional care into the community
• Children or youth enrolled in California Children's Services (CCS) or Whole Child Model (WCM) who experience food insecurity, housing instability, or have a history of Adverse Child Experiences (ACE).

The Role of ECM Care Coordinators

Care coordinators under ECM are formally referred to as Lead Care Managers (LCMs). They help the patient coordinate their entire life, covering the medical, social, and behavioral aspects.

The coordinators have the following responsibilities:

• To be the boots on the ground: Unlike traditional case managers who are based in the office, LCMs are field-based. They go beyond the office and call center to visit patients in their living rooms, homeless shelters, encampments, parks, etc. In so doing, they can spot gaps they can help fill.
• Medication reconciliation: When a patient is seeing several providers, there is a need for medication reconciliation to avoid conflicting prescriptions. LCMs physically check the patient's medicine cabinet and communicate any discrepancies/conflicts to the primary care provider.
• Scheduling and logistics: Some patients may miss appointments because of a lack of transportation or because of cognitive issues that hamper scheduling. LCMs can handle scheduling, arrange transportation, and call the patient on the day of the appointment to ensure they show up.
• Community support: To close the loop, LCMs refer patients to community support resources where necessary. It should be an active process that includes helping the patient make the phone call, fill out the required form, etc.

How Does the ECM Process Work?

ECM identifies patients who have historically fallen through the cracks, engages them, and helps them stabilize their health.

The process typically unfolds as follows:

• Identification: You can find eligible patients in your own clinical data or get referrals from other local community organizations. Also, Managed Care Plans may use algorithms to look for red flags (frequent ER visits, lack of primary care, missed prescriptions, etc.) and hand over a list of eligible patients to you.
• Outreach: The LCM reaches out to eligible patients by making field visits. They pitch the program and its benefits, and get explicit consent from the patient that they want to join.
• Assessment: The LCM then conducts a holistic evaluation of the patient’s medical history and social determinants of health (SDoH). The interview should be in a neutral place or in the beneficiary’s home.
• Care planning: A Living Care Plan is put in place to account for any changes in the beneficiary’s situation. The LCM co-creates the plan with the beneficiary to ensure the plan is driven by their unique goals.
• Implementation: The execution phase involves the actual coordination of social and medical services. It includes closed-loop referrals, health promotion/coaching, and appointment-related assistance.
• Review and transition: Based on results after reviews and reassessments, the intensity of the program may be scaled down. The ultimate goal is to help the beneficiary reach a point where they can transition to a lower level of care or be able to manage their situation on their own.

Tools to Improve Chronic Disease Management

Enhanced Care Management under Medi-Cal is a powerful service, but it is limited to specific populations of focus. Your chronic disease patients may or may not meet the eligibility criteria for ECM.

Fortunately, some key goals of ECM, like care coordination and enhanced support for complex chronic conditions, overlap with the goals of Medicare-billable programs like Advanced Primary Care Management (APCM) and Chronic Care Management (CCM).

However, unlike ECM, these programs do not require extensive field-based, in-person engagement.

You can rely more on technology, with the appropriate tools being:

• Remote patient care platforms: These cloud-based platforms integrate patient monitoring, communication (can be two-way), automated documentation, and workflow automation. A good example is our platform, KangarooHealth.
• Electronic Health Record (EHR): You’ll want the remote patient care platform to integrate with your EHR. KangarooHealth, for instance, integrates with popular EHRs like Athena, Epic, Cerner, and more.
• Connected devices: Where continuous monitoring is essential, you can automatically collect and transmit the patient’s physiological data (blood glucose levels, blood pressure, etc.) using connected devices (cellular-enabled glucometers, cuffs, etc.). You can offer this under the Remote Patient Monitoring (RPM) program.

How Does KangarooHealth Support Enhanced Care Management Programs?

KangarooHealth is a comprehensive care platform designed to help providers operationalize high-touch care for their most vulnerable patients with chronic conditions.

For those chronic patients at risk for avoidable hospital or Emergency Department utilization, our platform enables you to intervene early through RPM and CCM.

As an example, let’s explore how our CCM solution can help you with comprehensive care management.

How KangarooHealth Supports Chronic Care Management

CCM is designed for patients living with two or more chronic conditions. Our CCM solution can help you deliver coordinated, continuous, and patient-centered care to such individuals.

Here’s how:

• Seamless patient enrollment: We’ll help you identify eligible patients in your population. Once you obtain consent, our team will handle the enrollment process on your behalf.
• Proactive care coordination: To shift care from a reactive to proactive model, we offer trend analysis features, AI-driven risk assessment and triage, as well as tailored escalation protocols.
• Seamless communication: We offer omnichannel communication to enhance patient engagement and adherence. Your patients can stay connected to the care team through phone, text, or our in-app messaging feature.
• A dedicated clinical team: We have a multi-lingual clinical team to help manage the program and ensure each patient feels heard. With our team lending a hand, you won’t have to hire additional staff to roll out CCM.
• Compliant billing: We automatically track all relevant clinical time and automate documentation to ensure you are always billing-ready. It ensures you always get the reimbursements you qualify for.

With KangarooHealth, you can improve and scale patient-centered chronic care delivery without building new infrastructure or hiring new staff.

Contact us today to chat with an expert and explore our remote patient care solutions.

Frequently Asked Questions (FAQs)

Let’s answer some of the questions we get about enhanced care management:

How Do Managed Care Plans Approve ECM Services?

Managed Care Plans aim to ensure that ECM services are directed to those who are the most in need. As such, the first step is to verify that the referred patient falls within a covered ECM population through eligibility screening.

The plan will then evaluate medical necessity to determine whether ECM services are necessary, and approve or deny the referral based on the results of the evaluation.

What Happens During an ECM Intake Appointment?

An ECM intake appointment should happen in a neutral location or the beneficiary’s home. During the meeting, the LCM should:

• Set the tone (informal to build trust).
• Get consent for the program to start.
• Do a comprehensive assessment to evaluate the beneficiary’s clinical, functional, and social needs.
• Develop a living care plan that’s responsive to the beneficiary’s goals and changing circumstances.

Why Do Some Members Get Assigned Multiple Care Managers?

Ideally, you should have only one Lead Care Manager.

Multiple care managers may be suitable under rare situations where the beneficiary has complex needs.

What Documentation is Required for ECM Enrollment?

You’ll typically need:

• The ECM referral form
• An exclusionary screen checklist
• Member consent
• Document to support “population of focus”

How Long Can Enhanced Care Management Services Last?

It’s needs-based. Therefore, the beneficiary can use it for as long as they remain eligible.

However, the goal should be to empower the patient to reach a point where they don’t need the support.

Conclusion

Enhanced Care Management can help your organization transform care from a reactive model to a proactive, patient-centered approach. The result is significantly better outcomes.

At KangarooHealth, we’ve also seen firsthand how providing similar patient-centered support with RCM, CCM, and APCM improves outcomes for patients living with chronic conditions.

We consistently see higher patient engagement and medication adherence. We also see substantially lower readmission rates because, through remote monitoring, we can help providers prevent adverse events from escalating.

You, too, can roll out these patient-centered programs. Contact us today to implement RPM, CCM (reimbursable under both Medi-Cal and Medicare), or APCM (supported by Medicare).