Enhanced Care Management (ECM) Services
Whole-Person, Interdisciplinary Care for Complex Medical and Social Needs
What is ECM?
Enhanced Care Management (ECM) is a comprehensive approach designed to address both clinical and non-clinical needs of members with complex health conditions. Our services include:
- Systematic Coordination: Ensuring all aspects of your care are seamlessly integrated.
- Community-Based Support: Providing services within your community for better accessibility.
- Person-Centered Approach: Tailoring care plans to meet your unique needs and preferences.
Our Goals
We aim to:
- Improve Care Coordination: Streamlining communication among your healthcare providers.
- Integrate Services: Combining medical and social services for holistic care.
- Facilitate Community Resources: Connecting you with local support systems.
- Address Social Determinants of Health (SDOH): Considering factors like housing, transportation, and nutrition.
- Enhance Health Outcomes: Striving for better overall health and well-being.
- Reduce Unnecessary Utilization: Minimizing avoidable hospital visits and redundant services.
Populations We Serve
Sowing Seeds Health specializes in ECM services for all counties:
Individuals at Risk for Avoidable Hospital or Emergency Department (ED) Utilization
- We identify factors contributing to frequent hospital visits and work to mitigate them by:
- Connecting you with a Primary Care Provider (PCP).
- Addressing gaps in access to specialists or medications.
Adults Living in the Community and At Risk for Long-Term Care (LTC) Institutionalization
- Our intensive care coordination helps you remain safely at home by facilitating:
- Home Modifications.
- Respite Services.
- Personal Care and Homemaker Services.
- Medically Tailored Meals/Medically Supportive Food.
Adult Nursing Facility Residents Transitioning to the Community
- We assist residents interested in moving out of institutional settings by ensuring they:
- Are prepared for a successful transition.
- Can reside continuously in the community.
Sowing Seeds Health also serves the following populations, depending on county and health plan:
Individuals and Families Experiencing Homelessness
- Individuals and families experiencing homelessness are among the highest-need and most vulnerable individuals in Medi-Cal, in that they lack access to shelter and food, both of which are critical to health.
- These individuals often have extensive medical and behavioral health needs that are difficult to manage due to the social factors that influence their health. This can result in reduced quality of life and high utilization of avoidable, costly services in EDs and inpatient settings that could be avoided with more timely and appropriate care management and potentially the provision of Community Supports.
Individuals with Serious Mental Health and/or SUD Needs
- Members with serious mental health and SUD needs have disproportionately high rates of chronic physical health conditions as well as complex social needs.
- For children and youth, a number of social conditions and risk factors (e.g., exposure to trauma or other adverse childhood experiences (ACEs)) often present as behavioral health needs. ECM is critical to addressing risk early and averting long-term chronic illness.
Individuals Transitioning from Incarceration
- Many Members transitioning from incarceration have disproportionately high physical and behavioral health care needs that require ongoing treatment and medication maintenance when they are released into the community. Individuals re-entering the community often experience a lack of continuous physical and behavioral health care which results in a deterioration of their health, increased use of EDs and inpatient settings, and sometimes a return to incarceration.
- The goal is to establish a coordinated community reentry process that will assist people leaving incarceration in connecting to the services they need prior to release and upon re-entering their communities.
Children and Youth Enrolled in CCS (California Children's Services) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition
- CCS and CCS WCM serve some of Medi-Cal’s most vulnerable children. In addition to their physical health condition qualifying them for CCS/CCS WCM – such as cancer, cerebral palsy, and cystic fibrosis – these children often experience a high co-occurrence of social and behavioral health challenges beyond their CCS/CCS WCM qualifying condition.
- LCMs help take the navigational burden off children and their families, while helping Providers from the varied delivery systems harmonize with the family-centered plan of care.
Children and Youth Involved in Child Welfare
- Children and youth who are currently or were previously involved in Child Welfare Services provided through the California Department of Social Services (CDSS) often experience an extraordinary amount of transition and fragmentation of health care, social support services, and adult advocates in their childhoods.
- Many of the children in child welfare have co-occurring mental health and substance use treatment needs that are often unmet due to the challenge of navigating multiple and siloed service delivery systems.
Birth Equity Population of Focus
- Pregnant and postpartum individuals often require care that is accessed across many delivery systems to support themselves and their newborn. Pregnant and postpartum individuals can receive ECM if they qualify under any of the ECM Populations of Focus, and those that will go into effect in future months.
- The goal is to address known disparities in health and birth outcomes in racial and ethnic groups with high maternal morbidity and mortality rate in recognition that living within communities subject to historically poor birth outcome disparities related to social inequity is itself a risk factor that can be addressed through comprehensive, whole-person care management.