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By Jason Bloome
In December 2023 a California Health Care Foundation survey found only 47% of primary care providers and 55% of hospital-based discharge planning staff and social workers were aware of California Advancing and Innovating Medi-Cal (CalAIM): the state’s innovative $12 billion program to improve quality of life and health outcomes by implementing Medi-Cal system changes including the consolidation and streamlining of existing programs, improving service delivery and payment reforms. By 2027, the state will transition to statewide Managed Long Term Support and Services (MLTSS).
CalAIM goals include ensuring people who need the most help and support receive it by using proactive outreach to enroll people with complex care needs into efficient care systems and using a no “wrong door” approach for people seeking help.
CalAIM involves the use of state contracted Managed Care Plans (MCPs) to offer members Enhanced Care Management (ECM) and Community Supports (CS). ECM involves the use of comprehensive care management for Medi-Cal members with complex care needs and CS (known nationwide as In Lieu of Services or ILOS) are optional cost-efficient, medically appropriate alternative services CalAIM MCPs can offer members “in lieu of” traditional Medi-Cal services (e.g., payments to skilled nursing facility – SNFs) to prevent unnecessary institutionalization, emergency room or hospital stays.
CalAIM MCPs have the option of offering members an array of 14 CS:
- Housing Transition Navigation Services
- Housing Deposits
- Housing Tenancy and Sustaining Services
- Short-Term Post-Hospitalization Housing
- Recuperative Care (Medical Respite)
- Respite Services
- Day Habilitation Programs
- Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for the Elderly (RCFE) and Adult Residential Facilities (ARF)
- Community Transition Services/Nursing Facility Transition to a Home
- Personal Care and Homemaker Services
- Environmental Accessibility Adaptations (Home Modifications)
- Medically Supportive Food/Meals/Medically Tailored Meals
- Sobering Centers
- Asthma Remediation
Every quarter the state publishes CS and ECM implementation data reports (including the charts below) with the latest 2nd Quarter report released in November 2023 at: https://www.dhcs.ca.gov/Documents/MCQMD/ECM-and-Community-Supports-Q2-2023-Implementation-Update.pdf.
Enhanced Care Management (ECM)
As of June 2023, there were 140,886 members enrolled with ECM statewide with the largest number of ECM users consisting of individuals at risk for hospitalization or emergency department (71,248) followed by individuals with substance abuse issues (57,995) and for individuals experiencing homelessness (50,970).
Most ECM users are 18-64 years of age (85%), Hispanic (39%), and women (56%).
Community Supports
As of June 2023, there were 75,834 individuals enrolled with CS, with the top 3 categories: Housing Transition Navigation Services (28,966), Medically Tailored Meals or Medically Supportive Food (26,824) and Housing Tenancy and Sustaining Services (20,197).
Most CS users are Hispanic (35%), 18-64 years of age (77%) are Female (52%) and speak English (78%).
To increase CS uptake the Department of Health Care Services (DHCS) encourages community-based organizations, CS Providers, primary care providers, hospital-based social workers and other health care professionals to refer members to CalAIM MCPs offering CS and ECM programs.
A useful directory for CalAIM ECM and CS offered by each CalAIM MCPs can be found DHCS CalAIM webpage, under Additional Resource Options, Community Supports by Election and County at: https://www.dhcs.ca.gov/CalAIM/ECM/Pages/Resources.aspx. Some CalAIM MCPs offering CS and ECM in 2024 include CalOptima, LA Care, Healthnet, Anthem, Blue Cross, Molina, Kaiser, the Inland Empire Health Plan and the Health Plan of San Mateo.
Jason Bloome is owner of Connections – Care Home Consultants, an information and referral agency for care homes for the elderly in Southern California.
