ECM Core Services
The Plan will work closely with contracted Enhanced Care Management (ECM) providers to deliver all core service components of ECM to each of the ECM provider’s assigned members, in compliance with the Plan’s policies and procedures. It is absolutely essential that ECM providers deliver all seven core services to each enrolled member. The core services of ECM consist of the following core services.
Outreach and Engagement of Members into ECM
See Section 4.4.1.
Comprehensive Assessment and Care Management Plan
ECM providers are required to provide person-centered care management by working with the member to assess risk, needs, goals, barriers, and preferences, and have a care management plan that coordinates and integrates all of the member's clinical and non-clinical health care-related needs. Key components to this core service provision include:
- In-person contact.
- Person-centered.
- Comprehensive assessment.
- Member-centered care plan.
- Timely reassessment.
ECM providers are required to engage with each member assigned to receive ECM primarily through in-person contact. Public health precautions and recommendations should be used to accomplish the community-based, in-person approach of ECM. When in-person communication is unavailable or does not meet the needs of the member, the ECM provider is expected to use alternative methods (including innovative use of telehealth) to provide culturally appropriate and accessible communication according to member choice.
ECM providers are required to identify necessary clinical and non-clinical resources that may be needed to appropriately assess member health status and gaps in care and may be needed to inform the development of an individualized care management plan. ECM providers are required to initiate an assessment within 30 days and complete the assessment’s essential elements needed to develop plan of care within 60 days after member opt-in. ECM providers are encouraged to initiate and complete the assessment as soon as possible.
The comprehensive assessment may need to be completed during multiple member visits, adhering to the timeliness requirements above. During the assessment of the ECM member, critical services and referrals are encouraged to be provided as timely as possible. The full assessment and care plan do not have to be completed in full before a member is connected to any critical services identified.
ECM providers are required to develop a comprehensive, individualized, person-centered care plan by working with the member to assess strengths, risks, needs, goals, barriers, and preferences (including cultural and linguistic) and to make recommendations for service needs. This includes collaborating with the member and the member’s support network, leveraging input from the member’s family member(s), guardian, authorized representative, caregiver, authorized support person, and/or care team members, as appropriate.
ECM providers are required to create the member’s care plan immediately following the member assessment. ECM providers are expected to incorporate into the member’s care plan identified needs and strategies to address those needs, including, but not limited to, physical health, mental health, substance use disorder (SUD), community-based long-term services and supports (LTSS), oral health, palliative care, social supports and social determinants of health (SDOH). ECM providers are required to ensure the care plan is updated at a frequency appropriate for the member’s individual progress or changes in needs, and at minimum twice a month. ECM providers must ensure the assessment and care plan are reviewed, maintained and updated under appropriate clinical oversight. Care plan updates should occur regularly – for example, after reassessment or transitions of care, and when a new need is identified.
ECM members will have varying levels of acuity and will require different levels of service intensity and frequency of contact with the ECM provider’s multi-disciplinary care team. The diagram below illustrates the order of operations in developing and maintaining the member’s care plan.
Risk Assessment
ECM providers are required to conduct a comprehensive assessment that identifies a member’s physical health, mental health, SUD, community-based LTSS, oral health, palliative care, social supports and SDOH. ECM providers are required to start a member’s assessment within 30 days and complete a member’s assessment within 60 days of the member’s enrollment in ECM. ECM providers are encouraged to initiate and complete the assessment as soon as possible.
The assessment used must include all required assessment questions identified in the Plan’s standard ECM assessment template at a minimum to meet ECM program requirements. Standard ECM assessment templates are available on the the Plan California Advancing and Innovating Medi-Cal (CalAIM) provider resource page.
The risk assessment is used to assess an ECM member’s current health status, establish a platform to begin building care management and coordination goals, and develop an individualized care plan. ECM providers must reassess the member when clinically indicated or new needs are identified, or after transitions of care. Care plans should be updated during reassessments to address any changes in the member’s condition.
In addition to the member assessment, ECM providers are encouraged to review the Plan data and reports, electronic health records, medications, and other available clinical and non-clinical data sources to inform the care plan.
ECM providers are required to submit assessments to the Plan at a frequency to be communicated by the Plan.
Care Plan
ECM providers are required to create the member’s care plan immediately (as timely as feasible) following the member assessment. This is a requirement for every member as part of the initiation of ECM services. The care plan is a dynamic and person-centered plan of care that is maintained by ECM providers, and includes comprehensive input from the member, member’s authorized representative, PCP, specialists, and other service providers in accordance with the member’s wishes.
Informed by the assessment, the ECM provider will develop the member’s care plan together with appropriate stakeholders, including the member, the member’s providers, and the member’s family or support persons. The Plan recommends the member’s care plan includes the problem (opportunity), interventions, goals and barriers. ThePlan recommends goals be SMART (specific, measurable, achievable, realistic and time bound).
The ECM provider should update the care plan as appropriate when goals are modified, new needs or goals are identified, after transition of care, or when a member’s health is reassessed. The frequency for updating the care plan should be appropriate to the member’s needs, when the member is reassessed, and when transitions in care or changes in member health, functional, or social status occur. The care plan will track and coordinate information on referrals, follow ups, and transitions in care.
The ECM provider will document member acuity as part of the care plan and will maintain an appropriate level of contact with ECM members for their health status and goals. ECM providers are required to submit care plans to the Plan at a frequency to be communicated by the Plan.
Enhanced Coordination of Care
ECM providers are responsible for the ongoing care coordination for ECM enrolled members. ECM providers are encouraged to use case conferences to ensure integrated, effective implementation of the care management plan. Regular and very frequent member support and coordination services are essential to the success of ECM. Member contact should be in person wherever feasible and according to member preferences. Key components to this service provision include:
- Member care plan implementation.
- Continuous and integrated care.
- Treatment adherence. Communication.
- Fostered and ongoing engagement with member.
ECM providers are responsible for organizing patient care activities, as laid out in the care management plan, sharing information with the member’s multi-disciplinary care team, and implementing activities identified in the member’s care management plan.
ECM providers are responsible for maintaining regular contact with all providers that are identified as being a part of the member’s multi-disciplinary care team. The care team’s input is necessary for successful implementation of member goals and needs. ECM providers are responsible to ensure care is continuous and integrated among all service providers and referring to and following up with all referrals and services, including primary care, specialty referrals, SUD treatment, LTSS, oral health, palliative care, necessary community-based and social services, and all other the Plan-aligned available services. This includes following up with members to ensure all services were rendered (i.e., closed loop referrals).
ECM providers are responsible for providing support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, providing appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.
ECM providers are responsible for communicating the member’s needs and preferences timely to the member’s multi-disciplinary care team in a manner that ensures safe, appropriate, and effective person-centered care. ECM providers are responsible for ensuring regular contact with the member and their supports - family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s), when appropriate, consistent with the care plan.
Stakeholders, such as internal Plan business units, may reach out to ECM providers to help coordinate care or follow up with members.
Acuity Tiering Guidance and Frequency of Contact (Post-Enrollment)
The following criteria are offered by the Plan as a recommendation for determining frequency of ECM provider contact, and subject to the clinical judgement of the ECM provider based on the member’s needs and intensity of service provision. It is anticipated that members may move between tiers based on clinical or psychosocial needs.
Tier 1: High Acuity, minimum one contact per week if any of the below apply
- Newly enrolled in ECM (in the last month).
- Emergency department visit or hospitalization (in the last 30 days).
- New diagnosis or new initiation of treatment (in last 30 days).
- Documented or known non-adherence (medication, treatment or appointments).
- Little or no identified social support.
- Homeless or recently secured permanent housing (within the last 90 days).
Tier 2: Moderate Acuity, minimum biweekly (2x/month) contact if any of the below apply
- Emergency department visit or hospitalization in the last two - six months.
- Newly sustained treatment adherence (medications, appointments).
- Newly integrated social support.
- Secured permanent housing within last three - six months.
- At risk of homelessness.
Tier 3: Low Acuity, minimum monthly contact if any of the below apply
- Clinically stable on examination and laboratory findings (in maintenance phase).
- No emergency department visit or hospitalization (in the last six months).
- Ongoing treatment adherence (medications, appointments).
- Strong family/social support.
- Stable housing.
- On target to achieve at least one care plan goal (in the next three months).
Health Promotion
- ECM providers are responsible for Health Promotion, following the federal care coordination and continuity of care requirements (42 CFR 438.208(b)). Key components to this service provision include, but are not limited to:
- Working with the member to identify and build on successes and potential family and/or support networks.
- Member skill development, such as coaching to support lifestyle choices based on healthy behavior with the goal of supporting the member’s ability to monitor and manage their health.
- Strengthening the member’s skills that enable them to identify and access resources to assist them in managing their conditions.
- Linking members to resources for smoking cessation, managing members chronic conditions, self-help recovery resources and other services based on member needs and preferences.
- Promoting self-management by utilizing evidence-based practices, such as motivational interviewing, to engage and help the member participate in their care.
Transitional Care Services (TCS)
Transitional Care Services (TCS) include services intended to support members and their families and/or support networks as members transfer from one setting or level of care to another, including, but not limited to: discharges from hospitals, institutions, other acute care facilities, and skilled nursing facilities (SNFs) to home or community-based settings, Community Supports placements (including sobering centers, recuperative care and short-term post hospitalization), post-acute care facilities, or long-term care (LTC) settings. Although it is not a required component of TCS at this time, ECM providers are strongly encouraged to provide emergency department follow-up as part of TCS.
ECM providers are responsible for ensuring ECM members receive TCS to support members and their families and/or support networks as members transfer from one setting or level of care to another. TCS for ECM members should always extend at least thirty (30) days post-discharge to help avoid unnecessary readmissions.
ECM providers are required to sign up for and have a reliable Health Information Exchange (HIE) platform that provides admission-discharge-transfer feeds support with TCS. L.A. Care will provide admission-discharge-transfer feeds to ECM providers through Point Click Care. ECM providers are required to sign up for Point Click Care and turn on notifications.
ECM Provider and Lead Care Manager Responsibilities
ECM providers are expected to support members’ transitions from discharge planning until they have been successfully connected to all needed services and supports. The ECM Lead Care Manager is responsible for ensuring collaboration, communication, and coordination with members and their families/support persons/guardians, hospitals, LTSS, physicians (including the member’s PCP), nurses, social workers, discharge planners, and service providers to facilitate safe and successful transitions.
While the ECM Lead Care Manager does not need to perform all activities directly, they must coordinate and ensure completion of the TCS tasks. The ECM Lead Care Manager is responsible for ensuring all TCS are completed including, but not limited to:
Coordinating with Discharge Facility: Upon notification of a member’s transition, the ECM Lead Care Manager must begin outreach to the member and the discharging facility within twenty-four (24) hours to begin coordination and understanding of the potential needs and the needed follow-up plans for the member. ECM providers should provide information to the hospital discharge planners or discharging facility staff about ECM so that collaboration on behalf of the member can occur in a timely manner and that the member does not receive two different discharge planning documents. The ECM Lead Care Manager must also coordinate with the discharging facility to ensure the member participates in the discharge plan and receives and understands information about their needed care from the discharging facility.
- Discharge Risk Assessment: The discharge risk assessment supports the discharge planning process by helping to assess a member’s risk of re-institutionalization, re-hospitalization, destabilization of a mental health condition, and/or SUD relapse following an admission. It also helps to identify interventions/services that benefit the member.
- The ECM Lead Care Manager must ensure a discharge risk assessment is completed at any time during the inpatient admission or after discharge if the member has discharged prior to ECM outreach. This must include reviewing information from the discharging facility’s assessment(s) and discharge planning process (e.g., the discharge summary). The ECM Lead Care Manager must also ensure the discharge risk assessment is shared with appropriate parties such as the PCP, the member, and other service providers involved in the member’s care.
- It is recommended that the ECM provider consider the use of the Modified LACE Tool. This tool will yield a risk score of (low, moderate or high) indicating the member’s risk for re-admission. Members who score at a high risk of readmission are considered to be high acuity. The ECM provider is expected to identify interventions and services that benefit the member and address their needs.
- Discharge Summary/Planning Document: The ECM Lead Care Manager must ensure a discharge summary/planning document is created and shared with the member (if the member accepts a copy), PCP, and if applicable, receiving facility (e.g., skilled nursing facility (SNF), LTC, or acute rehab unit). This includes ensuring the member has the ECM Lead Care Manager’s contact information.
- A best practice is for the ECM Lead Care Manager to work with the discharging facility to ensure that the ECM Lead Care Manager’s name and contact information are integrated into the discharge summary documents that the member receives. The ECM Lead Care Manager may consider faxing a TCS Admission Notification Letter to the discharge facility that will inform the facility and PCP about the member’s enrollment in ECM services and the assigned ECM Lead Care Manager’s name and contact information. The TCS Admission Letter explains the purpose of TCS and requests the facility to share the ECM Lead Care Manager’s contact information directly with the member and include it in the discharge document. The ECM Lead Care Manager should also request that the facility send a copy of the discharge summary when it becomes available along with medical records relevant to coordination.
- Medication Reconciliation: Lack of medication reconciliation presents a significant risk for adverse drug events, especially for the highest risk populations. Accurate and timely medication reconciliation is a critical element of TCS for ensuring patient safety during transitions of care.
- The ECM Lead Care Manager must ensure medication reconciliation is completed post-discharge. This means medication reconciliation should be completed upon discharge by the discharging facility (pre-discharge) and a second reconciliation must be completed after discharge once the member is in their new setting (post-discharge). This can be done by the follow-up provider, such as the PCP, home health provider, or by the ECM Lead Care Manager if they hold an appropriate license, or by another team member on the ECM care team that has an appropriate license, in a manner that is consistent with California’s licensing and scope of practice requirements, as well as applicable federal and state regulations.
- Closed Loop Referrals: The ECM Lead Care Manager must ensure member is connected to Community Supports as needed. This includes ensuring completion of referrals to social service organizations, and referrals to necessary at-home services (durable medical equipment, home health, along with others) and follow-up on referrals made with internal and external providers to ensure services were rendered.
- Transportation: The ECM Lead Care Manager is responsible for arranging transportation for transitional care, including the use of non-medical transportation (NMT) and non-emergency medical transportation (NEMT). The ECM provider is responsible for developing policies to arrange transportation for transitional care.
- Post-discharge Follow-up: The ECM Lead Care Manager must ensure needed post-discharge services are provided and follow-ups are completed. The ECM Lead Care Manager is responsible for contacting the member no later than seven (7) days of discharge depending on the needs and acuity of the member.
- The Lead Care Manager must continue to support the member in all needed TCS identified at discharge, as well as any new needs identified through engagement with the member or their care providers. Post-discharge services include:
- Reviewing the discharge instructions with the member.
- Ensuring the member understands the process of navigating any resources or referrals initiated during their admission and addressing the potential delays with accessing these services.
- Supporting the member in addressing barriers that prevent the member from following up with the discharge orders. This includes timely scheduling of follow-up appointments with recommended outpatient providers and/or community partners, arranging transportation to any follow-up appointments and connecting the member to the PCP within seven (7) days post-discharge.
- The Lead Care Manager must continue to support the member in all needed TCS identified at discharge, as well as any new needs identified through engagement with the member or their care providers. Post-discharge services include:
Member and Family Support Services
ECM providers are required to provide individual and family support services to the ECM member, with the goal of ensuring that both the member and their family/support persons are knowledgeable about the member’s needs, care plan, and follow-up. Key components to this service provision include:
Member chosen family/support.
- ECM Lead Care Manager.
- Provide education on the members’ conditions and care instructions.
- Ensure each member and their supports are aware of the care plan and participate in its development, as appropriate.
ECM providers are responsible for documenting a member’s designated supports - family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s). ECM providers are also responsible for ensuring all appropriate authorizations are in place to ensure effective communication between the ECM providers, the member and/or their family member(s), guardian, caregiver, and/or authorized support person(s) and the Plan, as applicable.
The ECM provider is responsible through the ECM service provision includes activities to ensure the member and their supports – family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s) – are knowledgeable about the member’s conditions with the overall goal of improving the member’s care planning and follow-up, adherence to treatment, and medication management, in accordance with federal, state and local privacy and confidentiality laws.
The ECM provider must ensure the member’s ECM provider serves as the primary point of contact for the member and their supports –family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s).
The ECM provider must identify supports needed for the member and/or their family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s) to manage the member’s condition and assist them in accessing needed support services.
The ECM provider must provide for appropriate education of the member and/or their family member(s), authorized representative, guardian, caregiver, and/or authorized support person(s) about care instructions for the member.
The ECM provider must ensure that the member has a copy of their care plan and is information about how to request updates.
Coordination of and Referral to Community and Social Support Services
The ECM provider is responsible for coordination of and referral to community and social support services. Key components to this service provision include:
Member chosen family/support.
- ECM Lead Care Manager.
- Provide education on the resources available to the member.
- Ensure the care plan is updated to reflect the involvement of community and social support services.
- Follow up to ensure and document the coordination of services with community and social support services.
The ECM provider must determine the appropriate services to meet the needs of ECM members, including the services that address SDOH needs, including housing and services offered by the Plan as Community Supports. Additionally, the ECM provider is responsible for coordinating and referring members to available community resources and following up with members to ensure services were rendered (i.e., closed loop referrals).
ECM providers are encouraged to build and strengthen strong relationships with community members to support this service provision. ECM providers are encouraged to maintain a community resource directory and/or actively utilize the online community resource referral platform offered by the Plan.