Enhanced Care Management (ECM) Benefit for Children and Youth Populations

Enhanced Care Management (ECM) is a new Medi-Cal benefit to better support populations of children and youth with complex clinical and non-clinical needs who access care in multiple delivery systems. It is available to eligible Medi-Cal managed care plan (MCP) members in all California counties to support comprehensive care management for their complex needs. Through ECM, children will have a single Lead Care Manager based in the community who will coordinate care and services among the physical, behavioral, dental, developmental, and social services delivery systems, making it easier for kids to get the right care at the right time.

ECM is also free! There is no added cost to families for ECM.

“For ECM to be effective, it is not one size fits all. Where we are most successful is where we are building on deep, local expertise and knowledge.”

– Dr. Palav Babaria, Chief Quality Officer and Deputy Director of Quality and Population Health Management at the Department of Health Care Services

What to know about ECM:

With ECM, a dedicated Lead Care Manager will coordinate health and health-related services, offering care on the phone, in-person, and/or where members live. A Lead Care Manager can help families:

  • Find doctors and make appointments
  • Arrange free transportation to and from appointments
  • Check on prescriptions and help get refills
  • Connect families with local resources and Community Supports for food, housing and other social services

Note that ECM does not replace:

  • A member’s benefits: It’s an additional benefit for Medi-Cal members
  • A member’s doctors: Members keep their current doctors and other providers
  • A member’s options: ECM is voluntary and members can cancel ECM at any time

ECM eligible populations

ECM is available to children and youth populations with high social and clinical risk enrolled in Medi-Cal managed care plans.

Population of Focus Children & Youth Adults
1 Individuals Experiencing Homelessness
2 Individuals At Risk for Avoidable Hospital or Emergency Department utilization
3 Individuals with Serious Mental Health and/or Substance Use Disorder Needs
4 Individuals Transitioning from Incarceration
5 Adults Living in the Community and At Risk for Long Term Care Institutionalization
6 Adult Nursing Facility Residents Transitioning to the Community
7 Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
8 Children and Youth Involved in Child Welfare
9 Birth Equity Population of Focus

Referrals for ECM services

The state wants all stakeholders to help spread the word about ECM and how it can benefit children and youth. Community members and health providers that already have a trusted relationship with families can refer individuals to their Medi-Cal managed care plan for ECM services. This means that Medi-Cal members can be referred for ECM in a variety of ways, including:

  • Clinical settings, such as primary care and specialty care clinics, hospitals, and county-based Behavioral Health
  • Community-based organizations
  • Local public health departments and programs
  • Educational settings like schools and child care centers
  • Regional Centers
  • Housing agencies
  • Medi-Cal members (a self-referral) or their family members
  • Medi-Cal Managed Care Plans

DHCS is streamlining and improving access to ECM by standardizing referrals and expediting the authorization process, policies that will take effect on January 1, 2025. For now, referrals for ECM are best directed to/through Medi-Cal Managed Care Plans (find managed care plans for each county in this directory).

A Review of the Early Experience with ECM Implementation

Children Now undertook this project to research, explore, and better understand the early implementation experience of the ECM benefit for children and youth. This project has been informed by a number of activities prior to the launch of the ECM benefit for children and youth, and throughout the first year-plus of implementation; activities included:

  • A series of formal and informal interviews with a variety of stakeholders, including Managed Care Representatives, ECM providers, parents/caregivers, care managers, other advocates, and vendors seeking to provide ECM for children and youth. See a partial list of key informants here. · Active participation in several DHCS workgroup and advisory groups, Providing Access and Transforming Health (PATH) Collaborative Planning Initiative (CPI) meetings, CalAIM Provider Forums, along with other legislative hearings, conferences panels, and ad hoc meetings related to Medi-Cal and Medi-Cal transformation.
  • Continuing engagement with parents and caregivers of children with special health care needs, including a series of focus groups held in 2023, to better understanding their perceptions, expectations, and concerns with ECM and care coordination.
  • Regular engagement and communication with DHCS officials on ECM implementation and to push forward a robust data and quality improvement reporting agenda that centers the needs and experiences of children and families. · A thorough review of DHCS policies & Quarterly Implementation Report data, the updated ECM Policy Guide the Population Health Management (PHM) Policy Guide, other MCP guidance, and other ECM materials to better understand the successes, opportunities, and direction of its rollout for Children and Youth.
  • An audit of ECM provider directories (in Summer 2024) for all Medi-Cal MCPs to gauge the robustness of provider networks for members, which can vary greatly depending on population of focus needs and geographic location.

The ECM benefit originally launched in 2022, and was expanded to children and youth populations in July 2023. Uptake in ECM has been slow, and so far, only about 12,000 children and youth statewide are enrolled in the ECM benefit. Statewide there is one ECM provider for every XX children and youth enrolled in ECM, but the distribution of ECM providers does not match up with the population and geographic needs of children and youth enrolled in ECM. Read the full summary of our initial look at ECM data here, and our most recent update here.

To provide ECM services to Medi-Cal members, managed care plans contract with a network of local ECM providers that may include, but are not limited to: California Children’s Services (CCS) providers, school-based health centers, primary care physicians, community health centers, local health departments, Indian Health Service Programs, First 5 County Commissions, community based organizations, and behavioral health entities, among others. Some ECM providers may also be delivering Community Supports services and may have a strong care coordination history, (e.g., a clinic or a home health organization). Managed Care Plans had time and incentives to build up ECM provider networks before the launch of the benefit for children and youth populations. However, MCP efforts to contract with qualified ECM providers to serve the unique needs of children and youth are still ongoing.

In our review of 44 Managed Care Plan provider directories, we found just over 860 ECM providers who explicitly serve children and youth, and over 900 total providers. Four health plans—Anthem Blue Cross, Santa Clara Health Plan, LA Care Health Plan, and Health Plan of San Mateo were excluded from this analysis due to the difficulty of analyzing their directories and/or broken links to access the directory. Of the providers listed, roughly half (453) serve children with medical complexity in the California Children’s Services (CCS) program. Shockingly, however, there were two plans, Cal Viva (in Fresno, Kings, Madera counties) and Health Plan of San Mateo (in San Mateo and Santa Clara counties) that appear to have no ECM providers for children enrolled in CCS. Community Health Group (in San Diego County) has the most ECM providers for children enrolled in CCS, who are also the most linguistically diverse. Although MCPs’ network directories must indicate which specific Population(s) of Focus each ECM Provider is equipped to serve, several directories used symbols and legends inconsistently (i.e. not differentiating symbols for children and adults) which make them difficult to navigate.

Through a number of interviews with ECM stakeholders, we heard some common themes about challenges with referral processes and contracting arrangements that have already been articulated and documented for adult populations. We heard that these implementation challenges were exacerbated for child and youth populations because of things like unclear and inconsistent population definitions and eligibility criteria for child/youth populations, poor understanding of the interaction with other programs & systems that exist exclusively for children and youth, and lack of minimum qualifications for ECM providers to meet the complex needs of children and families. As it relates to the first year of ECM implementation for children and youth POFs, we offer the following ten observations based on our research and monitoring of the ECM benefit:

  1. Children and youth populations are an ECM policy after-thought. The ECM benefit was clearly designed based on experience with adult populations. But children are over one-third of Medi-Cal members, and the ECM benefit for children and youth populations was launched 18 months after adult populations. During that time of delayed implementation, little was done to prepare and build capacity for how to deliver ECM right for children and youth. After all, DHCS held its first webinar about the ECM benefit for kids just on week before the benefit went live(!), and then five months later DHCS released a “spotlight” document explaining how the benefit might work for kids. Among folks knowledgeable about ECM, there still appears to be a lot of confusion about ECM for kids, particularly around eligibility criteria and provider matching; and there’s an eagerness for more clarity.
  2. The intense focus on ECM member and provider enrollment numbers has entirely eclipsed conversations of quality or outcomes for children and youth; and as a result, reliable networks of qualified ECM providers for children and youth do not robustly exist (yet). ECM implementation efforts seem entirely driven by numbers – numbers of ECM members enrolled and numbers of ECM providers on paper. This comes at the expense of any attention to the quality of providers, whether in terms of knowledge of child-serving systems and programs, sufficient skillset, cultural competency, etc.

Challenges in language access and cultural competency.

Challenges in lack of standardization across providers and varying quality of care.

Providers might agree to serve kids on paper, but the skillset is entirely different than what is required to serve the adult population—different considerations for interacting with parents, developmental milestones and health systems, intersections with schools, reliance on adults for transportation and communication, etc. Some CBOs – for good reason – do not want to expand services to children and youth who aren’t in their specific population, and many don’t want to serve children at all.

  1. For potential ECM providers, contracting is a big challenge and MCP payment schemes are not sustainable. Both ECM providers and MCP staff reported challenges in contracting for the ECM child-serving network. It seems that MCPs were not sure how to find qualified providers and that potential ECM providers were new to trusting and contracting with MCPs. Many providers, especially in non-clinical settings and for social service providers, have had to stand up new data exchange platforms and Electronic Health Record (EHR) systems at a huge
  2. financial and personnel cost. To be ECM providers, CBOs have had to create new processes for data-sharing, communication, and workflows across ECM and other providers. For many providers, it is an entirely new contracting process with more requirements, fee-for-service structure, legal questions and credentialling, and new data security measures. There are also privacy concerns for sharing sensitive SDOH data and a need for more staff who have expertise in medical billing and healthcare contracting. It is especially difficult for small providers and CBOs to navigate multiple MCPs and systems, data platforms, assessment tools, and referral forms.

Some providers are not even aware of CCS or that they are serving CCS children,

  1. There are outstanding questions and challenges about the role CHWs can play as ECM providers in order to sustainably deliver care coordination services by qualified and reliable providers.
    1. Challenges in maintaining and sustaining qualified ECM providers, and integrating with Community Health Worker benefit. Especially for small CBOs and providers, not all MCP payment structures ensure that ECM is financially sustainable. At least one county noted that the reimbursement structure that requires three contact meetings with members per month, including one in person, was not sustainable because families have complex and competing scheduling needs. There is confusion and fear of duplicating services with the Community Health Worker benefit, which is already considered to not pay enough.
    2. Challenges in avoiding duplication of services. One county described having to create an extremely bifurcated organizational structure wherein the nurse case managers, medical directors, and social workers handled CCS needs, and then the ECM lead care managers focus on SDOH. However, that requires a high level of collaboration and communication especially when the lead care manager comes from another vendor who might not use the same data exchange platform and the MCP isn’t actively helping. Many interviewees reported that clients feel pressured to choose between programs like TCM or existing care navigation supports and ECM, and often decline to switch to ECM.
  2. Administrative approvals and authorizations for ECM can delay access to care, or entirely miss an opportunity to engage a child, youth, or family. Streamlining is welcome and necessary because as it currently stands, the MCP administrative approval and authorizations are a barrier in getting Medi-Cal members connected to ECM services. Opportunities are lost when members and providers have to wait three or four weeks for approval of ECM services; the provider may not be able to contact the member anymore, or the member may have lost interest or trust in ECM during that time.
  3. Some children with medical complexity – especially in CCS WCM counties – are turned off from ECM because it introduces another care manager into their lives.
  4. About half of the children/youth involved in child welfare won’t be eligible for ECM, and the other half may not be getting much out of ECM either.
  5. Even with knowledge about the ECM benefit, referrals may not happen. Not enough providers and community members know about ECM. If they don’t know about it, they can’t refer, and if they don’t understand or trust it, they won’t refer. In fact, one community-based organization shared that they no longer refer their families to ECM if they are Kaiser members because families who were in need of support and appeared eligible for ECM were getting rejected by Kaiser.
    1. Challenges in identifying and enrolling ECM eligible individuals. While the State is encouraging community-based referrals through providers and agencies who already interact with potentially eligible enrollees, many ECM referrals appear to still coming from data mining and diagnosis codes. There is reported distrust among families of adding another person to a child’s already complex care landscape, inaccurate or inconsistent contact info for patients, and a lack of providers to make community referrals in the first place. In some cases, the providers who know children the best (e.g. CCS county offices, CBOS, etc.) have not been able to contract with an MCP and therefore cannot make referrals. Even when a member might be eligible, there are discrepancies in how some of DHCS’ eligibility criteria are interpreted, leading to members missing out on critical services.
  6. Nobody’s talking about dental care within the context of ECM….it’s not clear if dental need is captured at intake or as part of ECM care plans.
  7. Accountability for ECM for children and youth is elusive. E.g. DHCS is not yet monitoring or holding plans accountable for ECM enrollment or closed loop referrals to ECM. Plans have received millions in IPP payments specifically for the purpose of building networks, but no transparency or accountability that MCPs have used IPP to prepare for ECM for children and youth. …..ECM care goals can’t be successfully be met if there are services gaps
    1. Challenges in defining success and “graduating” ECM enrollees down once care goals are met. One health plan reported that nobody in the ECM universe had defined “graduation” and that it varies across plans and providers, especially for children in CCS who have often chronic, lifelong conditions. The focus has been on enrolling as many members as possible, sometimes without foresight or consideration of what graduating or transitioning looks like. While CHWs are considered one scale down, CHWs are often contracted out by providers and not mandatory for ECM providers to have in house, making connecting ECM enrollees difficult.
    2. Challenges in capturing ECM enrollee and caregiver experience. While ECM remains a relatively new program, there have not been any robust discussions or guidance related to quality or feedback channels. Most experiences are shared anecdotally, and without a closed loop referral system that notifies the original referrer, it is difficult to tell who has received the services they were referred for and whether it was a positive experience. Care plans and quality metrics vary by MCP and by provider, making it difficult to tell if ECM is widely successful or not and what outcomes the State would like to see for kids. (E.g. reduced ER visits, school absenteeism, etc.)