OCTOBER 2023 PERSPECTIVES FROM THE FIELD by J. Duncan Moore, Jr Counties Lean into CalAIM T he state of California's comprehensive Medicaid continuing to care directly for people with complex reform effort, known as CalAIM (California health and social needs. Advancing and Innovating Medi-Cal), is one of the nation's most comprehensive and far-reaching efforts to make Medicaid truly patient centered. The Promising Approaches for need for these reforms is felt most strongly by people Californians with Complex with complex health and social needs, such as those with medical conditions who are also experiencing Needs homelessness, living with serious mental illness or The kernel at the heart of the CalAIM reforms for peo- substance use disorder, or returning to the commu- ple with complex needs is a new capability to cover nity after incarceration. Prior to CalAIM, California's services that address health related social needs in counties piloted innovative approaches to better serv- people's lives that, left unaddressed, may result in the ing people with complex needs through an initiative need for more intensive health care services down the known as Whole Person Care (WPC). Under WPC, road. Over half of Medi-Cal spending is attributable each pilot was administered directly by counties that to the 5% of enrollees with the highest needs. By inte- opted in and contributed local dollars to match federal grating medical services and social services, CalAIM's resources to fund the program. Each county devel- Enhanced Care Management and Community oped its own approach, and most counties provided Supports aim to improve health outcomes. They may direct services in addition to administering the pilot. also reduce the likelihood that Medi-Cal enrollees will have to be hospitalized later. For example, until The most promising services piloted in WPC have since someone's housing insecurity is addressed, it may be been scaled up statewide through CalAIM in the form difficult for them to get their health under control. of two programs: Enhanced Care Management (ECM) Therefore, CalAIM seeks to scale up the delivery of and Community Supports. However, the responsibility integrated services that address health-related social for administering those services has been passed from the counties to managed care plans (MCPs). Funding now flows through Medi-Cal MCPs and has moved away from a grant-like structure under WPC to fee-for- About the Perspectives from the Field Series service, capitated, and bundled payment structures As California's Department of Health Care Services under ECM and Community Supports. Yet, California's administers changes to the Medi-Cal program, es- counties still have important contributions to make. pecially those that are part of the CalAIM initiative, They are critical providers of care, as well as partners CHCF is intermittently publishing short reports that to both the MCPs and local organizations that support highlight the perspectives of those in the field who this high-need group of enrollees. are implementing the changes. These "Perspectives from the Field" seek to inform policymakers and This brief highlights how select counties have other health care leaders about insights and experi- adapted to CalAIM and are now acting as interme- ences from people on the ground who work directly diaries between MCPs and local providers while also with patients. needs, which have been shown in pilots to improve both administered by MCPs. ECM is a benefit, while outcomes while reducing spending. Community Supports are optional add-ons that plans can choose to offer. As a result, in some cases, services That scale-up is taking the form of Enhanced Care that were bundled under a WPC pilot are now divided Management (ECM) and Community Supports. into two separate programs. $ Enhanced Care Management (ECM) is a new Moving services into this structure is foundational statewide benefit designed to address the clini- to these services becoming permanent parts of the cal and non-clinical needs of complex enrollees in Medi-Cal program, but the changes in approach nine "populations of focus" through the intensive and funding have proved challenging for many pro- coordination of health and related services.1 The viders of services. The changes have imposed a program will meet people wherever they are - particularly steep learning curve on health program "on the street, in a shelter, in their doctor's office, administrators and providers in California's county or at home," per the state's Department of Health governments, who by and large are supportive of Care Services.2 Each patient who qualifies will have these new initiatives but have faced obstacles in the a single lead care manager - in effect, a naviga- first year of implementation. tor or concierge - who will coordinate physical, behavioral, dental, developmental, and social ser- vices. For patients with very complex needs, and Counties Serve as Central who are possibly not in optimal care settings, the Players intervention of a care coordinator who will advo- By history, tradition, and law, California's 58 coun- cate for them and weave together a net of services ties are responsible for a subset of services for their can literally be a life saver.3 residents. They enroll people in Medi-Cal and other $ Community Supports are optional new services that programs; administer - and in some cases provide can be provided by Medi-Cal managed care plans - behavioral health care and care for children with as cost-effective alternatives to medical care. There special health care needs; and provide social services are 14 Community Supports designed to address related to homelessness response, child welfare, social determinants of health. These include such aging, and disabilities. Counties also play an impor- offerings as medically supportive meals or hous- tant role in local law enforcement and correctional ing supports. Medi-Cal members may qualify for services. Community Supports regardless of whether they qualify for ECM services.4 California is somewhat unique in the freedom that the state has permitted its counties and the obliga- ECM and Community Supports are outgrowths of tions it imposes on them. Counties fund much of the Whole Person Care, which was piloted by 25 coun- non-federal share of the Medicaid-covered services ties between 2016 and 2021. Under the program, they administer. As a result, they have been allowed counties proposed structures and services for their to develop and manage services according to local pilots and were awarded funding, similar to grants, to needs and resources, within the frame of federal develop and lead programs to coordinate social ser- and state regulations. Not surprisingly, urban and vices, care management, outreach, and engagement suburban counties with high household incomes for people with complex needs. Concepts that yielded have been able to offer a richer array of services, favorable results in those selected counties have been while smaller or rural counties have fewer resources incorporated into these two programs, which are and services. Counties Lean into CalAIM 2 Some counties have public hospitals and clinics, which Management and Community Supports are going to have served as the hubs around which counties have help a lot of people in California." organized services for people with Medi-Cal coverage and those without insurance. In recent years, as part Commentary from the counties revolves around cer- of health reforms, these provider systems have moved tain themes: services out of hospitals and into various community settings that are closer to patients. $ Services $ Housing needs to be a top priority. In short, counties have the potential to serve as linch- pins in the delivery of whole-person care. This paper $ Integrating behavioral health into a seamless web highlights the perspective of counties that participated of services is critically important. in the Whole Person Care program, with the intent of identifying lessons learned and insights gained that $ Administration may be useful for those counties that are newer to this $ Work force hiring, training, and retention is a work and may be overwhelmed by the timelines, man- challenge. aged care requirements, and heightened expectations coming from the state. It will focus on four counties $ Data exchange and a strong information tech- in particular – Alameda, Placer, Ventura, and Contra nology infrastructure are essential. Costa – whose officials support the goals of CalAIM and have insights they want to share. $ Cost and Billing $ Billing for services is different than under WPC. "Expanding these programs so they serve more $ Payments do not cover the costs of services people – it's a good thing, I think. Enhanced provided. Care Management and Community Supports In the pages that follow we will hear from these are going to help a lot of people in California." county health administrators as they describe what – County official has worked and what remains to be refined in CalAIM implementation. To find out how counties have navigated these changes, we talked to people on the ground who have been charged with implementing ECM and Alameda County Community Supports. These public servants have In Alameda County, across the bay from San been working long hours against difficult headwinds, Francisco, the transition from Whole Person Care to first to introduce Whole Person Care, then to transform CalAIM has gone relatively smoothly. While it has not themselves into emergency pandemic response orga- been a copy-and-paste pivot, the county's pre-exist- nizations, and finally to reconfigure their programs to ing strong relationships with MCPs have eased the meet the requirements of CalAIM. It has left many of way forward. The foundation the county had in place them worn out and depleted. – supportive health plans, strong data collection tools, confidence from the board of supervisors, and high Yet there remains a spirit of optimism. Nobody we spoke morale among staff – ensured a high level of trust and to wishes to return to the status quo. As one county offi- capability. It was thus straightforward to set up regular cial told us, "Expanding these programs so they serve weekly meetings between county officials and health more people – it's a good thing, I think. Enhanced Care plans and to coordinate on data exchange. Counties Lean into CalAIM 3 "As we started CalAIM, there would be times when "We are excited about CalAIM being a way to we submitted a file, and it had errors. However, our work across our departments in a way we don't MCPs wouldn't flat-out reject our files, leading to no payment. We would work with them to resub- normally. We have weekly meetings with our mit with new information," said Kimia Pakdaman, homelessness, public health, and behavioral a program specialist for CalAIM at the Alameda health CalAIM teams. This is a different level of County Health Care Services Agency. "They have been very flexible in adjusting their systems to work coordination than we have had to do before. with our systems and processes. A lot of counties CalAIM requires that." have difficulty reaching their health plans or coming – Kimia Pakdaman, Alameda County Health Services Agency to agreement with the health plans. That is not the case in Alameda County." Every month, the county health agency sends its health plans a population health file that details key Two Medi-Cal managed care plans operate in information gathered from various systems of care for Alameda County: Anthem and the Alameda Alliance each of their members. "This type of data exchange for Health, a local not-for-profit entity. The Alliance has been very important in CalAIM, given the need covers the majority of Medi-Cal enrollees and has to work across the system, and also [to educate] the a broader network of local community-based pro- health plan on non-clinical data," Pakdaman said. viders. It is also very flexible in its operations. Anthem, a national plan, brings helpful capac- Internally within the county's health services agen- ity, particularly on IT and data exchange, as well cies, morale is high, reports Pakdaman. "There's an as a statewide perspective on what's important energy around making CalAIM work for us. We want to prioritize, Pakdaman said. to advocate for what helps people the best. We are excited about CalAIM being a way to work Pakdaman described her role as "to work across across our departments in a way we don't normally. We departments - Public Health, Office of Homeless have weekly meetings with our homelessness, public Care and Coordination, and Behavioral Health - to health, and behavioral health CalAIM teams. This is a make sure we're coordinated in implementation and different level of coordination than we have had to do communications with health plans and the state." before. CalAIM requires that." The county's Social Health Information Exchange The county's board of supervisors has been highly (SHIE) was a major legacy left from the Whole supportive of the CalAIM transformation, particu- Person Care pilot program. This repository receives larly when it comes to the criminal legal aspects data from 19 sources across organizations that work of the program. "They have safety net responsibili- in the areas of behavioral health, homelessness, ties," said Aneeka Chaudhry, Assistant Director of managed care, physical health, criminal justice, and the Alameda County Health Care Services Agency. public health. The SHIE can assist in rounding out a "Community-based organizations are such a big complete picture of each person's engagement voice in our local community, our board wants with the safety net and other aspects of the care to make sure there is diversity in the provider base. delivery system. They want to make sure the providers resemble the people who need services." Counties Lean into CalAIM 4 Many of these small community-based organizations state has put out a couple of incentive programs that (CBOs) are providers of housing services, one of the have given us a chance to work with our managed care anchors of the CalAIM model. Often, they do not plans on key homelessness services." have experience billing Medi-Cal. This is where the county can offer real value by helping new providers The county administration gets a lot of inquiries from understand billing and claims - which has benefits for providers that offer services to meet the social needs MCPs, CBOs, and the clients themselves. of the Medi-Cal client base and want to learn about and understand CalAIM. The county offers education "In the managed care space, they are supposed to and training for small providers to help them connect deliver care in a certain way. Then there is the home- to the MCPs and considers this capacity-building and lessness space, a separate system of care," Chaudhry infrastructure support to be critical for its local CBOs. said. Housing is very often the key to stabilizing a patient's health status; without it, they can lurch from emergency to emergency, and for Medi-Cal patients, Placer County the MCP is expected to coordinate the care and foot For many years, Placer County has placed an empha- the bill. sis on housing people with complex needs, which set it in good stead for the rollout of Whole Person "Health plans and the housing system speak Care. Building on that foundation made for a smooth transition under CalAIM, with little disruption for different languages and have different things Medi-Cal enrollees. to report to the state. But the state has put out a couple of incentive programs that have Geoffrey L. Smith, the program lead for CalAIM, is especially proud of Placer County's success in finding given us a chance to work with our managed permanent housing for people experiencing home- care plans on key homelessness services." lessness. "When Whole Person Care finished, we were – Aneeka Chaudhry, Alameda County Health Care Services Agency at about 180," he said. "A few months later we got to 200. I only counted people as housed when they were "We have had to do a lot of work with our partners permanently housed. It was a pie in the sky goal, but to understand the homelessness system of care," she we actually reached it!" said. For example, the US Department of Housing and Urban Development requires housing providers Smith came to Placer to start the WPC program. "I to have coordinated entry, that is, a single assessment would hear these programs saying, 'We housed eight of health, housing, and income factors. Linking the people this month.' They'd house somebody in unsus- services surrounding homelessness and health care tainable fashion," by throwing a lot of money around has been a useful role for the county to fill. that wouldn't be available in three to six months. "I made it a focus to follow our clients. If they became "If we focus on people who have high needs or unhoused, we uncounted them," he said. He sees are behaviorally complex, housing is often also many of Placer's innovations incorporated into the an issue," Chaudhry said. "We can't use the Medicaid statewide rollout of ECM and Community Supports. money for rent, so we work [with] our health plans to find different pathways to housing. Health plans and Smith cites the flexibility of the WPC program as a key the housing system speak different languages and to its success; every county established its own pri- have different things to report to the state. But the orities and customized its program to address them. Counties Lean into CalAIM 5 Placer's program was tailored to people coming out we'd have four or five staff helping somebody moving of jail or prison, people experiencing homelessness, into a new place. Now we can do a little bit of that but people with mental health conditions, and people not nearly the same. You have to be more judicious who use a lot of acute or crisis services. To support about the services you provide. That's been a difficult them, Placer's WPC pilot had four service bundles: transition for my team, to be able to provide intensive 1) medical respite, 2) comprehensive complex care individual services and then go to a model that is not coordination, 3) outreach and engagement, and 4) the same," said Smith. housing. The housing program included dedicated housing coordinators who worked directly with clients "It was really nice to be a part of that program that was to assist with rent subsidies, all in a bundled rate. And so well funded, have all the success, see people get those bundles left more money to work with, which housed," Smith continued. "It's inspiring to be a day- afforded favorable staff ratios. to-day part of their lives, to make a difference. They are forever grateful." "It was really nice to be a part of that [Whole "For it to switch - small picture, that's been difficult. Person Care] program that was so well funded, Big picture, a lot of people need these services. But it's have all the success, see people get housed. not sustainable to provide those [whole-person care] services at that level to this many people." … For it to switch - small picture, that's been difficult. Big picture, a lot of people need these services. But it's not sustainable to provide Ventura County If there's a sweet spot for the implementation of ECM those [whole-person care] services at that level and Community Supports, Ventura County seems to to this many people." have found it. The programs that the county had pre- – Geoffrey L. Smith, Placer County viously set as priorities for Whole Person Care have been expanded under CalAIM. Solid MCP relation- With ECM and Community Supports, the MCPs set ships were already in place, and the county had a many of the parameters. In some cases, the funding trained and engaged social services work force ready from plans has required changes in care and staffing to pick up the gauntlet. Continuity of care was pre- models. At Whole Person Care's peak, Smith ran a served and enhanced. team of 20 health professionals and community health workers. "Now it's about seven, a huge diminution," "Enhanced Care Management looks remarkably like he said. ECM and Community Supports each have 3.5 our case management model," said Rachel Stern, MD, full-time staffers. Reimbursements from the plan don't the county's chief medical quality officer for ambu- cover the program costs for staff, IT, and administration, latory care, who came from San Francisco to help so the county has shifted staffers to other programs. implement CalAIM. It's designed to offer high-inten- sity, high-touch services for the 1%–5% of people with Care managers who had a case load of 12 to 15 people severe health problems, she said, adding: "We did not under Whole Person Care are now expected to handle have to change the clinical structure at all." 40 people based on the MCP's approaches and fund- ing levels. This alters the relationship between care That clinical outreach was directed toward peo- manager - the navigator whose job it is to link Medi- ple with extremely high use of acute services and Cal patients to services and benefits, make phone people with substance use disorders, people expe- calls, and organize doctor's visits - and client. "Before, riencing homelessness, or people recently released Counties Lean into CalAIM 6 from incarceration. The menu of Community Supports "They are having a hard time learning to bill. We fits right into their model. "Case management, hous- are asking them to do something that other ing services - we had pretty rapid standup capacity for those," said Deanna Handel, director of complex professional people identify as a major source care coordination and system integration for the of burnout." Ventura County Health Care Agency. They were – Rachel Stern, Ventura County Health Agency already doing recuperative care as well, also known as medical respite, and two county buildings are being Handel and Stern provided technical help to their retrofitted for recuperative care and housing. agency partners to teach them how to bill. MCPs, they pointed out, expect to get information through medi- Because patients were so familiar with the array of ser- cal billing and claims. Thus, the county officials had to vices and providers in Whole Person Care, the county take a social services model and turn it into a medical decided not to change the name of the service. "We billing model. That has been a huge lift. Just getting had good brand recognition," Stern said. "We didn't it set up required biweekly meetings with county IT want people to have the sense they are losing their and health records staffers and another set of meet- service" by rebranding it. ings with the MCPs. Patients like the multidisciplinary approach that the "It is extremely difficult to ask non-medically trained county offers, Handel said. "If you have a behavioral people to learn to do medical billing," Stern said. health condition, you have someone assess your men- Citing an example outside of CalAIM, she added "a tal condition. If you have a substance use disorder, doula is used to being paid a lump sum at the begin- you have access to a trained professional. They work ning for their services. Now that person has to bill in together in a coordinated way to address the entirety increments and provide diagnosis codes." of needs for our patients." As a physician, Stern learned the importance of billing Medically tailored meals are one of the new services early in her medical career. But that is not something under Community Supports that have enjoyed broad a community health worker expects to have to do. uptake, with well over 500 people in the county "Our community health workers are exceptional," receiving meals. The service was implemented by the she said. "They come from a similar background as county's Agency on Aging, which came into CalAIM the people they serve. Many are bilingual. They are with strong vendor connections after having distrib- so tied to the community. They are having a hard time uted thousands of meals to people in need during learning to bill. We are asking them to do something the pandemic. that other professional people identify as a major source of burnout." That agency lost its funding when COVID-19 relief money ended, however. "We said, your expertise is The county's close relationship with its local MCP, in providing meals. There is a Community Support for Gold Coast Health Plan, which is the sole public Medi- this," Stern recalled. "To do this, you have to learn Cal MCP in Ventura, has made the work move along how to accept referrals from the managed care plan more smoothly than it might have. "One thing we've and learn how to bill for the services. That's the hard- done well, we had a strong partnership with our plan," est thing for agencies and vendors to learn to do Handel said. "They recognized the fount of expertise under CalAIM." in the county to provide the services. They partnered with us in implementation of CalAIM." Counties Lean into CalAIM 7 "You'd think it would be easy for us to do this, but it These innovations worked. Hernandez and her col- has not been easy," Stern said. Handel added: "There leagues published a large-scale study of 58,000 has been one new change after the next in a six-month Medicaid enrollees looking at whether the case man- cycle. It's a lot to implement in a short time, and a lot agement program in Whole Person Care reduced to digest. That's been a struggle for both the counties medical care and expenses for the cohort.5 The study, and the plans." published in July 2022, found that the interven- tion reduced total inpatient admissions by 11% and reduced emergency department visits by 4%. The pro- Contra Costa County gram appeared to be particularly effective at reducing Contra Costa County's enthusiastic embrace of Whole avoidable hospital admissions for diagnoses such as Person Care produced real results that have been hypertension and diabetes complications. The great- incorporated into ECM and Community Supports. est reductions in ED and inpatient admissions were The loose, entrepreneurial spirit behind Whole Person seen for patients under 40 years old. In addition, rela- Care – and the flexibility in funding – allowed the tive to other groups, Black patients experienced the county to rapidly innovate and do things that oth- greatest reductions in inpatient admissions. Feedback erwise wouldn't have been possible under normal from case managers suggested that the program government procedures. "helped patients build trust with the health system, resolve basic social needs, and better navigate the "We gave out cell phones and saw how homeless care landscape." patients could use cellphones to get appointments," said Elizabeth Hernandez, quality director for the By formalizing the best of these innovations across Contra Costa Health Plan. the state and ensuring a dependable line of money, CalAIM has implicitly offered all Californians covered "We purchased Uber and Lyft for patients to get to through Medi-Cal the possibility of achieving similar social services and medical appointments. If some- advances. body needs to get to court or to the Medicaid office, Medicaid doesn't traditionally cover non-medical "Waivers are waivers, and they have an end; that transportation. Or housing deposits. We were paying was Whole Person Care," Hernandez said. "The first month's rent for patients." main advantage to CalAIM is that ECM is a benefit now. It's codified. Oftentimes grants make us lean on "Waivers are waivers, and they have an end; short-term structures and workarounds. Now there is sustainability and structure, and it's part of the ben- that was Whole Person Care," Hernandez said. efit package. And there is longevity, with a permanent "The main advantage to CalAIM is that ECM is funding stream. This allows us to create long-term sys- a benefit now. It's codified." tem design for our county." – Elizabeth Hernandez, Contra Costa Health Plan For county administrators the length and breadth of the state, that permanent funding creates a real opportunity to make solid gains in their local popula- tion's health status. Counties Lean into CalAIM 8 Conclusion CalAIM's Enhanced Care Management and Placer, Ventura, and Contra Costa have adapted to Community Supports build upon the successes and these changes, leveraging their prior experience, lessons learned from the Whole Person Care pilot pro- data infrastructure, and trust-based relationships to grams implemented by various counties. The transition forge strong partnerships with managed care plans to to CalAIM has not been without its challenges, par- ensure continuity of care. Counties play a critical role ticularly in the reconfiguration of funding streams and in delivering patient-centered care, combining medi- the shift of responsibilities from counties to managed cal and social services to enhance health outcomes, care plans. However, leaders in counties like Alameda, and potentially reducing long-term healthcare costs. Counties Lean into CalAIM 9 About the Author Endnotes J. Duncan Moore, Jr, is a freelance writer based in 1. Medi-Cal Transformation: Enhanced Care Management (PDF), California Department of Health Care Services (DHCS) , Chicago who has been writing about health care for accessed October 18, 2023. more than 25 years. 2. "Enhanced Care Management and Community Supports," DHCS, last modified August 28, 2023. About the Foundation 3. J. Duncan Moore, Jr., "How a Managed Care Plan Helped a Young Man Move Out of a Nursing Home," CHCF Blog, The California Health Care Foundation (CHCF) is an December 13, 2022. independent, nonprofit philanthropy that works to 4. For a detailed history and evaluation of the transition from improve the health care system so that all Californians Whole Person Care, see: Nadereh Pourat et al. Final Evaluation have the care they need. We focus especially on mak- of California's Whole Person Care (WPC) Program (PDF), UCLA Center for Health Policy Research, December 2022. ing sure the system works for Californians with low incomes and for communities who have traditionally 5. Daniel M. Brown et al. "Effect of Social Needs Case Management on Hospital use Among Adult Medicaid faced the greatest barriers to care. We partner with Beneficiaries a Randomized Study," Ann Intern Med. 175, leaders across the health care safety net to ensure they No. 8 (Aug. 2022): 1109-1117. have the data and resources to make care more just and to drive improvement in a complex system. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. Counties Lean into CalAIM 10