VOTC, Inc. Enhanced Care Management (ECM)

The VOTC, Inc. ECM Program is assigned to Partnership HealthPlan of California (PHC) Medi-Cal members enrolled in one of our programs or by outside referrals.

The Member must be identified as meeting criteria in one of the following four (4) Populations of Focus eligible for ECM benefits: Homelessness, High Utilizers, Individuals with Serious Mental Illness (SMI) or substance use disorder (SUD), and/or Children or Youth with Complex Physical, Behavioral or Developmental Health Needs.

VOTC, Inc.’s Enhanced Care Management Program offers guidance and linkages for optimal health and personal growth. The member will work with a VOTC, Inc. ECM Lead Care Manager to develop a Care Management Plan to address any physical health, mental health, developmental health, substance use disorder, oral health, and transitional care need barriers the member may have prevented them from a successful and purpose-filled life. 

VOTC, Inc. ECM Core Service Components:

Outreach & Engagement

  • VOTC ECM shall use available data to prioritize outreach and engagement of members addressing members with the most immeadiate needs first.
  • VOTC ECM will make no less than three attempts within 30-days to outreach and engage with the member.
  • Upon engagement, VOTC ECM shall obtain the member's written consent for VOTC ECM services using Release of Information (ROI) forms.

Comprehensive Assessment

  • VOTC ECM will perform a comprehensive assessment to determine ECM engagement level and assisting in creating the member's Care Management Plan (CMP).
  • Identifying necessary clinical and non-clinical resources that may be needed to appropriately assess Member health status and gaps in care.

Care Management Plan (CMP)

  • VOTC ECM shall work with the member, guardian, caregiver, authorized representative (AR), and/or other authorized person(s) as appropriate to assess strengths, risks, needs, goals and preferences to make recommendations for service needs.
  • The Lead Care Manager is responsible for documenting and updating the member's CMP every 30 days; or more frequently if the member's care needs or preferences indicate such.
  • The CMP shall contain at minimum, needs, strategies, and patient prioritized goals surrounding care coordination needs for services including but not limited to the following: (a) Physical Health; (b) Mental Health; (c) Developmental Health; (d) Substance Use Disorder (SUD); (e) Oral Health; (f) Necessary Community-Based and/or Social Services; (g) Health Promotion; (h) Transitional Care Needs; (i) Member and/or Family Supports.
  • The Lead Care Manager shall make available to the member a copy of the CMP upon enrollment in ECM and/or upon member request.
  • VOTC ECM shall ensure that the member's CMP contains appropriate clinical oversight.

Enhanced Coordination of Care

  • Organizing member care activities, as laid out in the CMP, and sharing information with those involved as part of the member's multi-disciplinary care team.
  • Implementing activities identified in the member's CMP.
  • Maintaining regular contact with all Providers that are identified as being part of the member's multi-disciplinary care team, whose input is necessary for successful implementation of member goals and needs.
  • Ensuring care is continuous and integrated among all service Providers and referring to and following up with primary care, physical and developmental health, mental health, SUD treatment, oral health, palliative care, trauma-informed care, and necessary community-based and social services, including housing, as needed.
  • Providing support to engage the member in their treatment, including coordination for medication review and/or reconciliation, scheduling appointments, provindg appointment reminders, coordinating transportation, accompaniment to critical appointments, and identifying and helping to address other barriers to member engagement in treatment.
  • Communicating the member's needs and preferences timely to the member's multi-disciplinary care team in a manner that ensures safe, appropriate, and effective person-centered care.
  • Ensuring regular contact with the member and their family member(s), guardian, Authorized Representative, caregiver, and/or authorized support person(s), when appropriate, consistent with the Care Management Plan (CMP).

Health Promotion

  • Working with members to identify and build on successes and potential family and/or support networks.
  • Providing services to encourage and support members to make lifestyle choices based on healthy behavior, with the goal of supporting members' ability to successfully monitor and manage their health.
  • Supporting members in strengthening skills that enable them to identify and access resources to assit in mamaging their conditions and preventing other chronic conditions.

Comprehensive Transitional Care (Developing strategies to reduce avoidable member admission and readmissions into Emergency Departments)

  • Developing and regularly updating a transition plan for the member.
  • Evaluating a member's medical care needs and coordinating any support services to facilitate safe and appropriate transitions from and among treatment facilities, including admissions and discharges.
  • Tracking each member's admission/discharge to or from an emergency department, hospital inpatient facility, skilled nursing facility, residnetial or treatment facility, incarceration facility, or other treatment center and communicating with the appropriate care team members.
  • Coordinating medication review/reconciliation.
  • Providing adherence support and referral to appropriate services.

Member and Family Supports

  • Documenting a member's authorized family member(s), guardian, Authorized Representative, caregiver, and/or other authorized support person(s) and ensuring all required authorizations are in place to ensure effective communication between VOTC ECM; the member and/or their family member(s). Authorized Representative's, guardian, caregiver, and/or authorized person(s).
  • Activities to ensure the member and/or their family member(s), guardian, Authorized Representative, caregiver, and/or authorized support person(s) are knowledgeable about the member's conditon(s), with the overall goal of improving the member's care planning and follow-up, adherence to treatment, and medication management, in accordance with federal, state, and local privacy and confidentiality laws.
  • Ensuring the member's ECM Lead Care Manager serves as the primary point of contact for the member and/or family member(s), guardian, Authorized Representative, caregiver, and/or other authorized support person(s).
  • Identifying supports needed for the member and/or their family member(s), Authorized Representative, guardian, caregiver, and/or authorized support person(s) to manage the member's condition and assist them in accessing needed support services.
  • Providing for appropriate education of the member and/or their family member(s), Authorized Representative, caregiver, and/or authorized support person(s) about care instructions for the member.
  • Ensuring that the member has a copy of their Care Management Plan (CMP) and information about how to request updates.

Coordination of and Referral to Community and Social Support Services

  • Determining appropriate services to meet the needs of members, including services that address social detriments of health needs, including housing, and services offered by Community Supports.
  • Coordinating and referring members to available community resources and following up with members to ensure services were rendered.

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