Maria, a 58-year-old Medi-Cal member, had spent years navigating the healthcare system in a reactive way. Living with diabetes and asthma, she frequently found herself in the emergency room—not because her conditions were untreatable, but because they were unmanaged.
Without a consistent relationship with a primary care provider and facing barriers like unreliable transportation and financial stress, Maria often waited until symptoms became severe before seeking help. Over time, this pattern became her normal.
Her story is representative of many high-risk members—individuals who don’t lack access to healthcare, but lack connection, coordination, and support.
01. Challanges
Maria’s situation wasn’t caused by a single issue—it was the result of multiple, compounding barriers:
Frequent emergency room utilization
- ER visits became her default entry point into care
- Conditions escalated due to delayed intervention
Lack of primary care engagement
- No consistent provider relationship
- Preventive care was largely absent
Medication mismanagement
- Confusion about dosages and timing
- Inconsistent adherence
Transportation and access barriers
- Missed appointments due to lack of reliable transportation
- Limited ability to coordinate follow-ups
Low system navigation confidence
- Uncertainty about where to go for help
- No single point of contact
These challenges created a cycle where Maria was constantly reacting to health issues rather than preventing them.
02. Approach
Through Enhanced Care Management (ECM), Maria was introduced to a model built around proactive, relationship-driven care. Instead of episodic interactions, Maria was supported by a dedicated care team that focused on continuity and trust.
The approach centered on:
Establishing consistent communication through regular check-ins
Meeting Maria where she was—both physically and emotionally
Simplifying her care journey into manageable steps
Coordinating across all providers to eliminate gaps
Over time, the care team became a reliable presence in her life—not just during crises, but in day-to-day health management.
03. What ECM Provided
The ECM program delivered structured, high-touch support:
Dedicated care coordination
- Centralized communication across providers
- Alignment between primary care and specialists
Ongoing member engagement
- Weekly outreach via phone and in-person visits
- Continuous monitoring of needs and barriers
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Healthcare navigation support
- Scheduling and confirming appointments
- Guidance on when and where to seek care
Medication support
- Clear, simplified instructions
- Reinforcement through regular follow-up
Social determinants of health (SDOH) support
- Transportation coordination
- Connection to community-based resources
Single point of contact
- Someone Maria could call before issues escalated
04. Outcome
As the ECM model took effect, Maria’s healthcare journey began to shift in meaningful ways:
Reduced reliance on emergency care
- ER visits became less frequent
- Early intervention prevented escalation
Increased primary care engagement
- Regular visits became part of her routine
- Preventive care replaced reactive care
Improved self-management
- Greater confidence in handling medications
- Better awareness of symptoms and next steps
Stabilized overall health
- Fewer acute episodes
- More consistent day-to-day well-being
Stronger sense of support
- No longer navigating the system alone
- Increased trust in care providers
Key shift: Maria moved from being overwhelmed by the system to being supported within it.
