• ECM Provider Toolkit
• ECM Outreach Toolkit
• DHCS ECM for Children and Youth Populations of Focus Spotlight
• ECM and Community Supports Policy Cheat Sheet
• Providing Access and Transforming Health (PATH): Enables California community-based organizations (CBOs), public hospitals, county agencies, Medi-Cal Tribal and designees of Indian Health Programs, and others to successfully participate in the Medi-Cal delivery system as California widely implements Enhanced Care Management (ECM) and Community Supports and Justice Involved services under CalAIM. Interested providers may find the Providing Access and Transforming Health (PATH) Funding and Engagement Benefits Guide helpful.

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.)