Strengthening Comprehensive Care Management for Medi-Cal Members

Peach Tree Healthcare, a PATH Capacity and Infrastructure Transition, Expansion, and Development (CITED) awardee, shares how one of their clients was referred to the Enhanced Care Management (ECM) benefit by her primary care physician (PCP) because of her many visits to the emergency room, multiple chronic conditions, and socio-economic barriers to accessible, equitable care. 

The client consistently missed appointments and had her behavioral health services discontinued because she didn’t access services. The client was unable to take care of her health because of the stress brought on by financial burdens and a lack of transportation to health providers. The assigned case manager built a rapport with the client to navigate priorities and create a care plan that addressed health and socio-economic barriers. The client was connected with a transportation provider and worked with the case manager to learn how to schedule appointments. The case manager provided the client with a pocket agenda and showed the client how to efficiently use the calendar to write down appointments and tasks, reducing no-show appointments.

The case manager counseled the client on how to prepare for appointments and accompanied the client to doctor appointments to ensure the client was learning to advocate for themself and understand what was discussed, improving adherence to treatment. In addition to ensuring the client was prioritizing their health, the case manager assisted the client with calling the Social Security office and provided tips on how to speak with the representative and what to ask to resolve an issue. Once the issue was resolved, the client was assigned to a payee to ensure their rent and bills were paid on time. Since the client was discharged from county behavioral health services, the case manager connected the client  with another therapist and psychiatrist.

Thanks to ECM services, the client now has all the tools to manage their chronic conditions, resolve issues through efficient communication, and utilize available resources.