Children - Key Activity 19

KEY ACTIVITY #19:

Provide Care Management


 

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.

Overview

Led by a care manager – a licensed clinician or a nonlicensed trained individual under clinical supervision – care management is an intervention intended to support the highest need individuals within your practice. Typically, these are individuals with multiple complex chronic illnesses and/or comorbid chronic medical and behavioral conditions. The services are more focused, require the development of a person-centered care plan, and are of higher intensity than care coordination services. A patient must consent to participate in care management activities. A care manager works directly with the patient and multidisciplinary care team members to identify, plan and implement person-centered goals and care. The care manager supports the individual in identifying and coordinating resources and referrals, as well as supporting self-management activities to attain optimal wellness.

There are varieties of care management, which differ in the population of focus, goals and intensity of support. The National Committee for Quality Assurance (NCQA) designates the following designations for care management programs:

  • Complex case management.
  • Transitional case management.
  • High-risk and high utilization.
  • Hospital case management.
  • Organization-defined programs.

The DHCS Enhanced Care Management benefit is available to a range of high needs Medi-Cal MCP enrollees. With respect to pediatrics, children who are eligible for ECM have complex physical, behavioral, developmental and/or oral health needs (e.g., California Children Services, foster care, youth with clinical high-risk syndrome or first episode of psychosis).

Care management provides a higher level of support to individuals who have medical, behavioral health and/or social needs that impact their ability to access appropriate levels of care. Individuals may be receiving frequent ER and hospital care that could be avoided with care management activities and/or patients may have significant social barriers (e.g., housing, food, substance use) that prevent them from accessing preventive and wellness care.

As part of care management, the patient’s medical, behavioral health and social health needs are directly addressed as part of the assessment and prioritized according to the patient's goals. For example, supporting the patient’s concerns around securing stable housing may be a first step to achieving better health. Addressing health-related social needs helps in reducing health disparities among different populations. Individuals with lower socioeconomic status or limited access to resources can be provided with resources to support these areas.

What patients are eligible for care management?

Individuals eligible for care management have high levels of need in one or more of the domains of medical, social or behavioral health. Children with complex medical needs or who require intensive support post hospital discharge may be eligible.

Medi-Cal members can also be connected to community support services to help address their health-related social needs, such as access to healthy foods or safe housing, to help with recovery from an illness.

What patients are eligible for Enhanced Care Management?

In California, Medi-Cal beneficiaries who experience high care management needs may be eligible for a Medi-Cal benefit known as Enhanced Care Management or ECM. Your MCP can provide you with details on patient eligibility and the requirements needed to provide ECM services to your patients. ECM is available to specific groups of Medi-Cal members, including the following, which pediatric practices may encounter:

  • Adults, unaccompanied youth and children, and families experiencing homelessness.
  • Adults, youth and children who are at risk for avoidable hospital or emergency department care.
  • Adults, youth and children with serious mental health and/or substance use disorder needs.
  • Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model with additional needs beyond their CCS condition(s).
  • Children and youth involved in child welfare (foster care).
  • Adults and youth who are transitioning from incarceration.
  • Pregnant and postpartum individuals; birth equity population of focus (starting in 2024).

How do we refer a patient who we think would benefit from ECM?

If you have a patient who may be a candidate for ECM or Community Sspports, you should contact the Medi-Cal managed care plan to inquire about services available through the patient’s health plan.

How can we provide care management services, including ECM services, in our practice?

Community practices are often well situated to provide care management services, as they are the site where patients seek or can be connected to care. Clinics may decide that they want to provide care management services, including ECM services. The following resources can help assess your capacity to provide care management services within your clinic structure.

Evidence base for this activity

  • Chuang E, Pourat N, Haley LA, O’Masta B, Albertson E, Lu C. Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration. Health Affairs. 2020 Apr 1;39(4):639–48.
  • Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, et al. Implementation of Care Management: An Analysis of Recent AHRQ Research. Medical Care Research and Review. 2016 Oct 23;75(1):46–65.