Central County Senior Services
a program of Alzheimer’s Orange County
Enhanced Care Management: Holistic Care for Complex Health and Social Needs
Enhanced Care Management (ECM) program 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.
In parternship with
Who We Serve
Older adults 60 years or older on Medi-Cal, who are high healthcare utilizers, at risk of institutionalization, or those transitioning from nursing facilities back into the community.
OUR SERVICES
– Outreach and engagement
– Health needs assessment and care planning
– Coordination of care
– Health Promotion
– Transitional care services
– Member and family support
– Coordination of and referral to community and social support services
BENEFITS
– Decreases inappropriate hospitalizations and duplication of services
– Improves care coordination
– Integrates services
– Addresses social determinants of health
– Facilitates community resources
– Improves health outcomes
ELIGIBILITY
The ECM Program is designed to help CalOptima members who meet at least one of the following:
• Older adults who have been hospitalized 5 or more times in the last 6 months or have 3 or more hospital or skilled nursing facility stays
• Older adults who are at risk of being institutionalized in a nursing home or facility who are struggling with:
– Activities of daily living (ADLs)
– Communication
– Accessing food
– Stable housing
– Making decisions
• Older adults who are in nursing facilities and transitioning back into the community who
- Are interested in moving out of the institution AND
- Are likely candidates to do so successfully AND
- Are able to reside continuously in the community
