Mark Humowiecki, JD, General Counsel & Senior Director
A bold experiment in complex care is underway in California. Approved by CMS on December 29, 2021, California Advancing and Innovating Medi-Cal (CalAIM), builds on California’s experience of whole-person care (WPC) pilots and health homes (HH) to fully integrate complex care services and benefits within managed care.
Two new major benefits — enhanced care management (ECM) and Community Supports (the latter of which is defined as 14 non-medical benefits to address health-related social needs) — will be delivered by community providers to defined populations with serious and complex health and social needs.
Other CalAIM initiatives will establish a cohesive statewide approach to population health management, strengthen the behavioral health continuum of care, help address poor health outcomes among justice-involved Medi-Cal eligible individuals re-entering their communities, and transition to statewide dual-eligible special needs plans and managed long-term services and supports.
Notes Dr. Michelle Schneiderman, Director of People-Centered Care at the California Health Care Foundation, CalAIM is “an ambitious initiative that, if implemented successfully, will transform a fragmented and complicated Medi-Cal program into one that is responsive, coordinated, comprehensive, and just.” While there is no question California has gotten the policy right, the true test of success will be in its implementation.
Implementation is everything
Under CalAIM, everyone in the system — health plans, health systems, community health centers, community-based organizations (CBOs), the workforce, and even Medi-Cal members — is being asked to do things differently. Three major areas of challenge and opportunity stand out as health plans and other stakeholders navigate the early days of implementation.
1. Supporting the workforce – Complex care requires a well-trained and supported interdisciplinary workforce capable of helping marginalized populations address a wide range of medical, behavioral, and social challenges. Designed to be different than traditional telephonic health plan models of care management, ECM is high-touch, whole-person focused, and delivered through in-person engagement “where they live, seek care, and choose to access services – on the street, in a shelter, in their doctor’s office, or at home.” The service must be provided by community-based providers and directed by and focused on the goals of the individual health plan member.
While some teams have deep experience in this mode of care management through HH and WPC pilots, many care managers will be asked to fundamentally change how they work with Medi-Cal members.
In our experience on the ground in Camden, frontline staff require new knowledge, skills, and attitudes to provide true person-centered care management. Special attention is required to help practitioners develop authentic healing relationships with individuals experiencing complex needs, many of whom have developed distrust of the healthcare system due to racism, stigma, and other forms of discrimination. Also needed are supervisors who provide the support and structure to build staff resilience, introspection, and flexibility as they work to support individuals with trauma history in navigating broken systems. To share our lessons learned after two decades in this space, we created a training toolkit structured around the complex care core competencies and offer live and virtual training opportunities — through our Camden Coalition Learning Center and technical assistance offerings — for front-line care managers and their supervisors to learn the knowledge and skills needed to deliver ECM services.
Workforce investments pay multiple dividends: patients and communities benefit when practitioners learn the biological, social, and/or structural causes of addiction, mental illness, homelessness and incarceration, and challenge the stereotypes that have caused these populations to receive inferior care. Practitioners can find great meaning and joy working in interdisciplinary teams and helping individuals become healthier and thrive in their community.
2. Expanding CBO capacity – Through Community Supports, CalAIM uses Medi-Cal funds to pay for high-impact, non-medical services that are essential to improving health and well-being, such as various housing supports, medically tailored meals, day programs, personal care services, and home modifications.
While these new healthcare investments are welcome, they occur in an environment of growing inequality and a starved social safety net, with need outpacing traditional human services and community development funding. Existing CBOs throughout California have the experience and community trust to deliver these new services, but many have never contracted with healthcare organizations, lack the organizational infrastructure (data security, electronic records, billing and coding, etc.) expected by health plans, and/or may not even be aware of CalAIM. Moreover, health plans are under considerable time pressure to secure contracts that cover their entire service area and may be tempted to contract with for-profit ventures who are new to the space rather than local CBOs who already provide the web of needed services.
This is a critical moment to invest in local CBOs — including the formation of CBO networks with lead agencies capable of servicing health plans on behalf of multiple organizations — and to strengthen the connections between healthcare and social care institutions. We know that complex care is a team sport that requires strong local ecosystems in which CBOs are treated as expert partners and have a voice in designing and executing new systems, including data sharing and referral workflows.
This is not to dismiss new technology platforms that can help CBOs better collaborate with healthcare organizations, but rather to recognize that technology alone is not a complete solution and that the tremendous infusion of public dollars represented by CalAIM must build community capacity rather than merely enrich entrepreneurs.
Several efforts are already underway, many funded by philanthropy, to educate CBOs about CalAIM, build CBO capacity, help form CBO networks, and promote contracting between health plans and CBOs. In addition, CMS has approved $1.85 billion for CalAIM’s Providing Access and Transforming Health (PATH) program, which can provide much needed capacity-building and support in the form of technology, transitional programs, and technical assistance.
Despite the sense of urgency, it is critical that health plans spend the time upfront to engage local communities in designing and building programs and systems that strengthen existing CBOs, rather than funding a parallel set of for-profit enterprises that are narrow in scope and do not have community roots. Such investments in CBOs can improve the long-term efficiency and sustainability of the human services sector, which ultimately is critical to advancing health equity and community well-being.
3. Simplifying systems – CalAIM promises to streamline and simplify systems, yet it relies on dozens of health plans to implement ECM, Community Supports, and other elements of reform. One danger is that each health plan imposes its own set of standards, metrics, technology solutions, and other requirements on its community providers.
While flexibility and innovation are important, too much variation in implementation can generate competing standards that create confusion and excess cost. The state plays a critical role in setting uniform standards, including the use of interoperable technology platforms, while avoiding over-prescribing processes that can interfere with innovation and are better left to individual health plans and partners to work out.
The state’s recent guidance on Member data sharing with ECM providers illustrates its attempt to achieve this balance. The state provides certain minimum requirements and rules on which data elements must be shared, while encouraging health plans, “especially those operating in the same county, [to] work collaboratively to establish common specifications for data elements where not otherwise defined and maintain common templates for the communication of this information.”
Achieving this balance between prescription and flexibility requires ongoing communication and compromise amongst all parties. Success demands that health plans and community providers take the time and effort to collaborate, despite being competitors, to further define data specifications and other implementation standards and practices in ways that work for everyone.
Done well, California’s experience will help establish new standards in a rapidly expanding market in which healthcare payers and providers buy care coordination and defined social care services for their members from networks of well-organized, high functioning community-based organizations.
Designing the future
Transformational change doesn’t happen overnight. Many elements of CalAIM, including certain services and populations of focus, are being implemented in phases over the next few years. The state just released a slate of new and updated guidance on participant eligibility, service definition, billing/coding, data sharing, and contracting terms, all of which are provisional and subject to change. The state is regularly holding webinars, engaging with stakeholders, and communicating its expectations and plans, while also showing a willingness to proceed iteratively and refine based on experience.
Much of the state’s current focus remains on clarifying policy, yet effective implementation will also require opportunities for stakeholders to share their early experiences – struggles and breakthroughs – with one another, as they collectively identify best practices. We are excited to be offering one such opportunity at our Putting Care at the Center 2022 conference, which will take place in Sacramento, CA, September 21-23 and feature four dedicated CalAIM town halls to explore early lessons in how CalAIM has been able to address homelessness, improve the health of justice-involved individuals, integrate social supports into Medicaid delivery, and more.
It’s also vital that Medi-Cal members who receive these new services be actively engaged as true partners in the planning, evaluation, and refinement of services – they are experts in navigating the various broken systems and have important ideas about how to improve and simplify services and supports. It takes thoughtful design and a commitment to share power to effectively engage and partner with beneficiaries and those with lived experience, but when done well, it can produce tremendous insights and begin to create the trust with the community that is essential to transformation.
CalAIM is an opportunity to transform the multiple systems that impact the health and well-being of those most in need, at an unprecedented size and scale. The work is not easy, but it is the work that needs to be done to improve outcomes and advance health equity at this critical time. With sustained effort and commitment to collaboration and learning – with partners, competitors, and the people served by the programs – CalAIM can teach the rest of the country a great deal about what it takes to implement complex care at scale. We must do so, however, by strengthening existing community institutions and not letting big players with big money overtake this endeavor. There is too much at stake.
Join the conversation about CalAIM — and learn about other innovations in complex care happening across the country — at Putting Care at the Center 2022, September 21-23 in Sacramento, CA.