Enhanced Care Management
ECM Services
ECM is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of Members with the most complex medical and social needs. ECM provides systematic coordination of services and comprehensive care management that is community based, interdisciplinary, high touch and person centered.
ECM offers comprehensive, whole person care management to high-need, high-cost Medi-Cal Managed Care Members, with the overarching goals of:
- Improving care coordination;
- Integrating services;
- Facilitating community resources;
- Addressing SDOH;
- Improving health outcomes; and
- Decreasing inappropriate utilization and duplication of services.
Population of Focus
Sowing Seeds Health is experienced in providing ECM services for the following three population of focus because of of our CHW's lived experience and our experience in providing primary care services for patients with complex medical needs.
Individuals At Risk for Avoidable Hospital or ED Utilization
Our ECM for this Population of Focus aims to reduce avoidable care in costly settings and settings that are of higher acuity than would be necessary with earlier and more whole-person care interventions and approaches.
The assessment and care planning process will identify the drivers of the ED or inpatient episodes in detail, which may extend beyond conditions into specific social needs. We will help members connect to their PCP, or selection of a different PCP. We will address any gaps in access to specialists or medication that may have driven the admission.
Adults Living in the Community and At Risk for LTC Institutionalization
Intensive care coordination through Sowing Seeds ECM can help adults continue to reside in the community who would otherwise have entered into an institutional setting for care. Our coordination of care may include referral of the following to help adults safely staying at home.
o Environmental Accessibility Adaptations (Home Modifications). o Respite Services.
o Personal Care and Homemaker Services.
o Medically Tailored Meals/Medically Supportive Food.
Adult Nursing Facility Residents Transitioning to the Community
Intensive care coordination through ECM can help nursing facility residents transition safely into the community.
Sowing Seeds Health will help those adult nursing facility residents who:
(1) Are interested in moving out of the institution; AND
(2) Are likely candidates to do so successfully; AND
(3) Are able to reside continuously in the community.