Q&A on Enhanced Care Management at AFS

In 2023, AFS rolled out a new program known as Enhanced Care Management (ECM). For a more detailed look at this new and innovative program, we recently sat down with Manisha Sandhu, Program Director of the AFS Oakland office who has helped to launch ECM in Alameda County. 

Can you provide a high-level overview of what Enhanced Care Management means at AFS? 

At AFS, Enhanced Care Management started out with Alameda County, and over the last six months, we have expanded to other counties including, Sacramento, Napa, Solano, Sonoma, San Francisco.  

This is a unique opportunity because we’re serving individuals and families that are not AFS clients. These are individuals not receiving AFS services like foster care or mental health. The referral base is strictly from managed care plans, so we’re working with the healthcare system. In Alameda County, we partner with Alameda Alliance, and in Sacramento, it’s with Kaiser Permanente. Each county, there’s a different managed care plan, but they’re all Medi-Cal recipients.  

We serve what we call a population of focus of which there are nine populations. In Alameda County, we provide a lot of services for the unhoused. Oakland has many homeless camps, and one of the families is living in one near our office.  

ECM is also for kids with complex mental health needs and pregnant women and families who need support and understanding of how to vide for their children and family. 

For Enhanced Care Management, the team is the lead care manager. There is a case manager who is assigned to the family. This is not individual based. It serves families, and the lead care manager can have up to 25 to 30 clients or families that they serve at once. Much of it is linking families to the resources they need to support them, for instance, not having to continuously seek health care. These are individuals who might be diabetic, so they’re always going to the hospital or getting some sort of treatment, but an LCM (Lead Care Manager) can help them with, let’s say, dietary plans so that they’re not having to go back and forth into a hospital setting to receive the care. 

It’s exciting because we’re implementing a brand-new program. I mean, we’ve been doing foster care for 45-50 years. 

AFS receives a referral, and we then meet the family in their community. We’re not asking them to come to the office. It’s like if they need us to meet them at their home, then we will meet them at their home. If they would prefer us to meet them in the community, then we will do that too. And we’re accessible. It’s just one of those services where the lead care managers are always in need because these families are vulnerable in different ways.  

We’re implementing and learning at the same time of some of this work crosses over with working with foster youth and CPS reporting, those things that we all learn and train on as a foster care agency. But this is also crossing over into enhanced care management. And the beauty of this is we meet them where they’re at, and prevention is a big part of this program.  

And we do offer support with reverse referrals. For example, if we have a young adult in one of our foster homes and they’re on the verge of transitioning into a different living arrangement. We’re contracted with Full Circle Health Network. I can go to them and say, I currently have this non-minor dependent who would like to live independently. I would like to reverse this referral because they’re an internal client already and request that ECM be a service that gets approved for this young person. We can follow that youth outside of care, like linking them to employment opportunities and seeking housing for them. It’s a matter of how to help them succeed once they’re no longer under the umbrella of AFS and fostering. That’s exciting.  

And for kids that reunify as well, I mean, we’ve never done that before, where we can follow a family post-reunification and support that family, because what we want to once again prevent is for kids to come back into care. The family has been working hard to earn this back, have their kids back home, and we can follow them. That’s another beautiful part about this service, there have been many cases where kids go home and, not the fault of the family, but they reoffend and here they come back again, and the whole cycle repeats for years.  

Can you speak a little bit about how a family would first enter the Enhanced Care Management orbit? What does the service model look like? What kind of services would an LCM provide? 

A supervising Lead Care Manager receives referrals directly from Full Circle. That LCM makes, at the very least, a phone call, to reach out to the family within five days of us receiving the referral.  

From that point, the next contact is an in-person visit. There must be one in-person visit per month. Our Lead Care Managers meet the families in their community. We also assess safety, so if the LCM feels unsure of whether they can go out and meet in the community, then we invite them to our office. The LCM meets the family and starts to build rapport and have an opportunity to explain how the services work. 

Some families are confused as to why we’re calling them and what this service is about. What they don’t realize, or maybe they’ve forgotten, is they recently went to a doctor. The doctor thought, “This could be a great opportunity for this family to receive ECM services.” The doctor then makes a direct referral. Some families forget that was talked about, so the first meeting is about educating them on how the LCM can help.  

A risk assessment is performed, and an individualized care plan with associated goals is created for the family. Sometimes families just need space to vent or share their struggles, so it could feel very much like a therapy session. We’re building rapport. After the first visit, LCMs reach out at least once per week via phone or Zoom. The LCMs have learned what resources to offer by doing research or collaborating with each other.   

For example, I had group supervision with three LCMs and a supervisor. It was like case consultation and resource sharing. We have one bilingual LCM because of a great need for Spanish families.  

So if I’m understanding correctly, the idea is essentially listening to the families, learning more about them, and then from there, trying to understand what their needs are, and then connecting them with relevant services, whether it’s additional health support, mental health support, housing, job, education – whatever they need, the LCM is helping to facilitate. Is that the idea? 

When you’re in dire situations, you’re not always thinking clearly. The LCM is there to home in on what is needed. And a lot of it is thinking outside of the box, too, and the bigger picture, because when you’re in crisis – and many of these families are in crisis – you’re stuck in the moment. The LCMs do that level of work and support them. 

Because ECM is different than what AFS has been doing historically, how do you determine success? 

Goals are identified through the individualized care plan. The goals can change. You could meet those goals in a certain time, and then new goals are added. That’s the tool the LCM and the families utilize to see whether to assess services and success for the family. 

The LCMs build relationships. This may be one of the first times families have an individual that’s just there for them and their kids. We currently have a family where the mom is a victim of domestic abuse. She needs support on how to leave the situation, which is a higher-level referral.  

Has AFS hired new staff for this program? 

Completely new. In Alameda County, AFS was approached by Chabot College to collaborate in an apprenticeship. These individuals have experience, have been system-involved, and want to go to school. These are people working on getting their AA degrees. 

Two of the three of our LCMs are apprentices, and they come with a high level of experience because they’ve lived in this world in different ways. Either they’ve been in foster care or they’re fostering their own relatives, but they want to go back to school and be social workers. They want to give back. The two apprentices are AFS employees going to school, and this was an opportunity for them to gain experience.  

And they came at a perfect time. We had just started talking about ECM, and then concurrently, the apprenticeship program approached us, and it was just like a beautiful fit because the two are a wealth of knowledge.  

What does the future look like for ECM? 

In Sacramento, San Francisco and Sonoma Counties, AFS has started receiving referrals and ECM is in its early stages. We also have the green light to support Napa and Solano counties. The Full Circle Network is contracted with several agencies like ours to funnel these referrals. AFS has been making a good impression because we’re highly responsive to their calls. We know it’s important for us to serve these individuals, and we have excited employees that want to support these families.  

We’ve received many kudos because the supervising LCMs are accessible all the time, and that’s just AFS in general. I feel like any service delivery, we’re accessible individuals, and if we’re not, there’s always somebody else that can support them. 

We’re six months into this program and so far, it’s been great. And I have to say that the LCMs, being new employees coming into a brand-new program as their first job within our agency, have flourished. 

Alternative Family Services

Alternative Family Services (AFS) provides thoughtful, informed foster care, adoption and mental health services throughout California’s San Francisco Bay Area and Greater Sacramento region. Since 1978, the mission of AFS has been – and continues to be – to support vulnerable children and families in need of stability, safety and well-being in communities through foster care, adoption and mental health services.

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