CalAIM’s next step for California’s whole person care utilizing Care Management and Care Coordination

As Governor Gavin Newsom stated, “[CalAIM] is a once in a generation opportunity to completely transform the Medicaid system in California”. To move towards this transformation means intensive care coordination services will need to be provided at the community level to address not only physical and behavioral health, but psychosocial needs as well. Initiatives that tightly align with the approach of CalAIM include focusing on population health, which involves matching the right patients to the right services at the right time and supporting coordination and access to services provided by counties and community-based organizations. This requires looking at the whole person and having the ability to see everything about an individual in a one-of-a-kind view, including all services they are and should be receiving.

As mentioned in our last blog post on CalAIM, we are reminded that “when talking about one’s health, it is not limited to just physical health. A person’s overall health has to do with mental, emotional, physical and spiritual well-being.”

Some of the focus comes from the call-out of populations with the most complex needs such as the following:

• People with significant behavioral health needs, including people with mental illness, serious emotional disturbance, and/or substance use disorder
• Seniors and people living with disabilities
• People experiencing homelessness who also have complex physical or behavioral health needs
• People transitioning from jail or prison back to the community who also have complex physical or behavioral health needs
• Children with complex medical conditions, such as cancer, epilepsy or congenital heart disease
• Children and youth in foster care

Many California providers are exploring solutions that allow them to apply different risk stratification to the populations.

Because providers are encouraged to look at the whole person, this requires a shift for providers as they move towards looking at what care is being provided to the individual overall, instead of just what their organization is providing. A major goal of CalAIM is to improve outcomes for millions of Californians covered by Medi-Cal, especially those that have complex needs. In many cases this will require even more coordination. This is where Enhanced Care Management can be the leading driver into accomplishing this goal.

A great example includes a new reimbursable, non-traditional services called sobering centers. Sobering centers offer a cost-effective alternative for providing care to intoxicated individuals whose public alcohol use puts themselves or others at risk, avoiding a potential trip to the emergency room or even jail. CalAIM has peaked new interest in this decades-old approach. With proven benefits, not just cost avoidance, individuals avoid potential negative outcomes such as deaths from underlying injuries, illness or suicide.

California has been moving in this direction for many years. In 2016, the California Department of Health Care Services (DHCS) completed a first round of a whole person care (WPC) application process and approved 18 lead entities to operate WPC pilots. In early 2017, DHCS conducted a second application process to expand current pilots and/or approve additional entities to operate WPC pilots. By 2020 DHCS had completed 25 pilots with a range of comprehensive services and supports to address unmet needs and improve the quality of care and outcomes of high-risk populations.  Many of the lessons learned during these pilots are driving CalAIM initiatives such as community-based assessments and disposition planning and the focus on the consumer experience.¹

Netsmart understands the connectedness needed for these initiatives and will advocate for you. We support the development and operation of community-based programs and are here to proactively address and help meet the needs to improve the overall health of the communities you serve. We know you and we’d like for you to get to know us too. Netsmart is California ready!

Sources:

¹ https://www.brightresearchgroup.com/wp-content/uploads/2019/09/Exec_Summary_Dissemination-Brief-Case-Conference_9.5.19_to_AC3.pdf