When her son turned 18, the letters kept coming — medical forms, legal notices, instructions she couldn’t read. Her son, who has Down syndrome and autism, was being asked to sign documents he didn’t have the capacity to complete. His mom knew something was wrong but didn’t know where to turn.
Under the hospital’s Enhanced Care Management (ECM) program, a lead care manager (LCM) stepped in, helping the Spanish‑speaking mother understand the conservatorship process and coordinating paperwork with clinicians and legal aid, even visiting the courthouse with her.
Along the way, the LCM secured food and utility assistance for them, worked with the son’s school to extend his term so he could graduate, and ensured a smooth transition into adult care.
“That’s really the heart of this program,” said Keri Carstairs, MD, vice president and chief population health officer at Rady Children’s Health in San Diego. “We’re walking alongside families.”
That kind of wraparound, relationship-based support is the backbone of the ECM program. What started as a trial initiative with three staff members serving five children has grown over four years into a pioneering health care model with 30 multidisciplinary staff working with more than 800 children and their families at any given time.
Since ECM’s inception, emergency department visits decreased by up to a fourth, and inpatient admissions fell by nearly half.
“By integrating the social, behavioral health, and medical care,” Carstairs said, “we’re really changing health care outcomes and giving families the tools they need to manage their children’s health care needs long-term.”
How it works
Enhanced Care Management is designed for children with the highest levels of complexity, including those with frequent avoidable emergency department use, complex chronic conditions, serious mental illness, homelessness, involvement with child welfare, or substance use challenges.
“This is the most vulnerable Medicaid population we serve,” Carstairs said. “Often it’s medical complexity layered on top of social complexity and behavioral health needs all at once.”
Each enrolled family is paired with a LCM who serves as the consistent point of contact from enrollment through program completion, coordinating care across specialties, supporting transitions between inpatient and outpatient settings, and helping families navigate the day-to-day challenges that often derail care plans.
LCMs don’t simply make arrangements over the phone or facilitate clinic visits. They visit the patients’ homes, their schools, and their community spaces. They get them to courthouses and shuttle them to foodbanks. They help complete housing negotiations, complete benefits paperwork, secure license renewals.
“In traditional health care, nobody has the time to do this,” Carstairs said. “If I’m spending two hours as a physician or nurse helping a family get food or transportation, I’m not billing for that and I’m not focusing on their medical care. But helping with the social needs is what allows the medical care to work.”
Rady Children’s can now bill for these services because of California’s Medicaid (Medi-Cal) structure. ECM is a Medi-Cal managed care benefit provided through an 1115 Medicaid waiver, which allows managed care plans to pay providers through per-member, per-month contracts for work that addresses both medical and social needs.
“For the first time, we’re actually getting paid to do this necessary and important work,” she said. “We’re not overpaid, but we can cover our costs and build a real program.”
State-supported expansion grants also allowed the hospital to hire and train staff ahead of enrollment growth, helping the program expand capacity without asking teams to absorb the work of growing the program on top of existing responsibilities.
A sustainable staffing model
Unlike traditional case management programs that rely primarily on licensed clinicians, ECM is built around staff who don’t need college degrees. More important than their resume is their real-world experience, which allows them to build trust with families and sustain engagement over time.
“We’re really intentional about who we hire,” Carstairs said. “We want people who know the community, who speak the language, who can say, ‘I’ve been through this. Let me help you.’”
The staffing model also helps make the program financially feasible and avoid some of the workforce challenges affecting clinical roles nationwide, especially in pediatrics.
“When we open one LCM position, we may get 50 applicants,” she said. “People are drawn to this work.”
LCMs are supervised by nurses, social workers, and physicians who provide clinical oversight, participate in interdisciplinary care reviews, and help guide complex medical decision-making. And they are trained in person-centered care, cultural sensitivity, and motivational interviewing, among other topics.
“We do a lot of training on how to deal with difficult situations, because there are things that come up with these families that can be very challenging,” Carstairs said.
How families move through the program
Patients that meet criteria are referred from across the health care system. Enrollment begins with a comprehensive health and social assessment by the LCM. The nurse and social worker review the assessment along with the patient’s chart to identify any care gaps.
Care planning is collaborative. The patient and family identify priorities, and an interdisciplinary care team builds a shared plan around those goals.
“We don’t start by telling families what to do,” Carstairs said. “We ask, ‘What do you need right now? What’s most important to you?’”
ECM is not an open-ended service. The program focuses on empowerment and transition, with clear graduation criteria. Families exit once they demonstrate confidence navigating care independently or transition to adult or community-based programs when appropriate.
“We want families to leave knowing they can navigate the system on their own,” Carstairs said.
Driving outcomes
Among patients enrolled in ECM:
- Emergency department visits decreased by approximately 18–25%.
- Inpatient admissions declined by about 40%, with even larger reductions among children with behavioral health needs.
- Well-child visit rates rose to more than 67%, exceeding internal program goals and outperforming many comparable Medicaid populations.
“That tells us we’re keeping kids out of the hospital, and we’re getting them back into primary care, where they belong,” Carstairs said. “More importantly, families are better equipped to manage their child’s needs.”
The data also underscores the level of need. Nearly two‑thirds of enrolled children screen positive for at least one social driver of health, most often food insecurity, transportation barriers, or housing instability.
“That’s exactly why this kind of model has to exist,” she said. “You can’t separate health from everything else going on in these families’ lives.”
How hospitals can replicate it
Carstairs emphasized that ECM can start small.
“Start with one population. Partner with one health plan,” she said. “Build something you can do well, measure it, and then grow.”
Success requires working widely with community partners and with disciplines across the hospital system.
“Many of our clients see multiple providers who have important information about what’s needed for successful outcomes. It’s critical for us to make sure that we’re talking with all of them,” Carstairs said.
The experience illustrates the importance of flexible Medicaid pathways supporting relationship-based care that addresses the medical and social needs together — particularly when they are complex — and underscores why protecting Medicaid funding is essential to sustaining programs like these.
Rady Children’s story shows how enhanced care management can move from concept to an operating model, delivering results that families feel and systems can measure.
