Enhanced Care Management Impact Evaluation 2021 Update

The Enhanced Care Management (ECM) intervention consists of training and coaching doctors and their teams to develop holistic care and pro-active outreach plans for chronically ill patients or those vulnerable to developing chronically illnesses. The core goal of ECM is to improve the quality of care provided to complex patients, including by increasing the use of preventive care, better coordinating care across health system levels, and increasing patient involvement in care. These elements can improve patient health and quality of life, and may reduce the need for curative medical services—for example, by supporting patients with diabetes to improve their diet and increase their level of fitness to limit further deterioration in their health.

ECM practices include improved tracking of tests and referrals, follow-up after hospital discharges, tracking medication adherence, monitoring between clinic visits, and focusing on achieving clinical quality. It includes four elements: identifying high-risk patients through risk stratification, developing care management plans by the primary care physician, proactively linking care providers together, and developing a team approach with patients and their caregivers.