The goal of ECM is to coordinate all primary, acute, behavioral, developmental, oral, social needs, and long-term services and supports for Members, including participating in the care planning process, regardless of setting.
ECM Providers deliver all core service components of ECM to each of the ECM Provider's assigned Members.
There are seven core services at the point of care:
Outreach and Engagement - Includes identifying (or accepting referrals for) members who are eligible for ECM. ECM Providers are responsible for reaching out to, and engaging assigned members, using multiple strategies for engagement.
Comprehensive Assessment and Care Management Plan - Includes assessing a member’s current health status including physical health, mental health, SUD, palliative, community based LTSS, oral health, social supports and SDOH needs. The ECM assessment is used to appropriately address the member’s health status and gaps in care and develop an individualized care plan.
Enhanced Coordination of Care - Includes the services necessary to implement the member’s care plan including but not limited to organizing member care activities as laid out in the care plan, referral coordination, medication review and/or reconciliation, scheduling appointments, coordinating transportation, treatment adherence, and communication with member’s multidisciplinary care team.
Health Promotion – Includes supporting member’s ability to monitor and manage their health and make lifestyle choices based on healthy behavior which may include health education, coaching, disease management, and motivational interviewing to assist the member with self-management of their health and social needs.
Transitional Care Services - Includes service intended to support Members and their families and/or support networks as Members transfer form one setting or level of care to another, including but not limited to discharges from hospitals, institutions, other acute care facilities, and SNFs to home or community-based settings, Community Supports, post-acute care activities, or LTC settings. Services include supporting member’s transition from discharge planning until they have been successfully connected to all needed supports, including coordinating with the PCP, ensuring a discharge risk assessment was completed during admission, ensuring the member receives only one integrated discharge planning document and shares a copy with the PCP, conducting a medication review/reconciliation, Closed Loop Referrals, scheduling follow up appointments with recommended outpatient Providers and/or community partners, etc.
Member and Family Supports - Includes identifying supports needed for the Member and/or their supports and conducting activities to ensure the Member and/or parent, caregiver, guardian other family member(s) and/or authorized support person (s) are knowledgeable about the Member’s condition (s) with the overall goal of improving the Member’s care planning and follow-up, adherence to treatment, and medication management.
Coordination of and Referral to Community and Social Support Services - Includes determining, coordinating, and referring members to the available community resources and follow up with the Member and/or parent, caregiver, guardian to ensure services were rendered.