At Venice Family Clinic, our commitment to our patients’ health doesn’t end when they leave the exam room. For some patients, staying on track with their care can be challenging because everyday obstacles get in the way, whether that’s stress about costs, difficulty accessing services or simply not knowing where to turn for help.
That’s where the Clinic’s care management team comes in. We offer two distinct programs – Resource Case Management and Enhanced Care Management – which offer short-term problem-solving and longer-term care coordination, respectively, across the Clinic’s service area. While their implementation is different, each patient-centered program’s goal is the same: to help patients follow through with their care plan and take charge of their health.
The Resource Case Management team includes four case managers, one of whom focuses specifically on the needs of pediatric patients. The Enhanced Care Management program has four lead care managers and a dedicated RN.
Read on to learn how these teams support patients and make a lasting difference in their health and lives.
What is Resource Case Management?
Resource Case Management (RCM) helps patients address a singular short-term barrier that can make it hard to follow through on their health care plan. They work with patients to find immediate, practical solutions – such as educating individuals experiencing homelessness about the Coordinated Entry System and how to access housing services through partners like The People Concern or St. Joseph Center. They also connect patients with local food programs or teach them how to access free transportation options through their health plan or other low-cost community resources.
Patients qualify if they screen positive for a social need that limits their ability to achieve better health. Then for the RCM team, it’s about listening, problem-solving, and removing the obstacles that patient faces.
“RCM is one of the most valuable investments I’ve seen an FQHC make,” says Belen Arangure, director of care management. “Not all patients qualify for case management through their health plan, and RCM helps bridge that gap, creating more equitable access to support those with unmet social or health needs. The team listens and leverages their knowledge about community resources – similar to air traffic controllers – to direct patients to the best external or internal resource that helps meet their immediate need.”
How is Enhanced Care Management different?
Enhanced Care Management (ECM) is a statewide initiative for Medi-Cal patients with more complex medical and social needs. While RCM focuses on immediate, short-term challenges, ECM takes the same patient-centered approach and extends it over time.
ECM lead care managers provide ongoing, one-on-one support for patients who meet specific eligibility criteria, which can include multiple chronic conditions, frequent avoidable hospital visits, serious mental health issues, substance use disorders or unstable housing.
ECM lead care managers coordinate all health and health-related care for as many as 45 patients on their caseload, providing a variety of supports uniquely tailored to each patient’s circumstance.
Each day brings something new. The work is hands-on and deeply personal.
“We’re like the patient’s guide through the health care system,” says Daisy Martinez, ECM lead care manager. “For example, if a patient’s PCP recommends the person see a cardiologist, I would check the status of the authorization with insurance, and then I’ll call the specialist to schedule the appointment. I’ll remind the patient about their appointment, and if they don’t have transportation, I’ll schedule a ride for them. After the appointment, I’ll call the specialist’s office, and if I find out they need a follow-up, I’ll schedule it if it isn’t already done. It sounds like a lot, but many of our patients don’t have other support. If I don’t help them, they might fall through the cracks, and their health will suffer.”
What medical support does the Clinic provide for ECM patients?
Patients in the ECM program benefit from a dedicated nurse who oversees their care plans, reviewing each patient’s medical history to identify risks and gaps in care. They collaborate with the primary care provider and the case management team to create a comprehensive care plan tailored to each patient’s unique needs.
“These are high-acuity patients dealing with very complicated health issues,” explains Sarah Pincu, RN and clinical consultant for the ECM program. “They might be struggling with low health literacy, or homelessness, or substance use or mental illness; but then on top of that have congestive heart failure and diabetes and chronic kidney disease. Our case managers are amazing, but they don’t have medical training, and that’s where I come in. I keep an eye on key indicators – vital signs, lab results or symptom changes – to provide medical oversight and help our patients understand how their diagnoses, medications and treatment plans all fit together.”
What kind of difference do these programs make for patients?
For patients, the impact often comes down to feeling supported and seen.
With RCM, a single conversation can lift a weight off someone’s shoulders. A patient experiencing homelessness is better prepared to navigate the complicated system to get housing.. Another who didn’t know where to turn for help with a short-term expense suddenly has options. The team also leapt into action in the aftermath of the Palisades and Eaton fires, connecting fire-impacted patients with financial support of up to $2,500 to cover housing and basic needs. These small wins restore a sense of stability and help patients feel more confident about managing their health.
Patients in ECM build an ongoing relationship with a care team that checks in regularly, helps them manage conditions, and keeps all their providers connected. Over time, that consistency builds trust, and that trust helps move their health forward, whether that means getting their A1c under control after years of struggling with diabetes, getting a long-delayed surgery or simply staying consistent with medications and keeping their appointments.
For both programs, the goal is progress and stability, helping patients build the foundation for better health and quality of life.
“We’re building genuine relationships that are helping people navigate our fragmented health care system,” says Nick Kaneshiro, ECM lead care manager. “Yes, I’m their case manager, and they’re my patient. But we get to know them pretty well, and at the end of the day, we’re all neighbors.”