In 2022, the California Department of Health Care Services (DHCS) will launch an ambitious and innovative program designed to better coordinate the physical, behavioral, and social needs of Medi-Cal members who live with the most complex conditions.

The California Advancing and Innovating Medi-Cal (CalAIM) program will build upon the plan-based Health Home Program (HHP) and county-based Whole Person Care (WPC) pilots that use whole-person care approaches to address underlying social determinants of health (SDOH).

CalAIM envisions enhanced coordination, integration, and information exchange among managed care plans (MCPs); physical, behavioral, community-based, and social service providers; and county agencies by establishing new benefits and services including:

• Enhanced Care Management (ECM) benefit, which will provide intensive whole-person care management and coordination to address the clinical and nonclinical needs of Medi-Cal members with complex needs. MCPs will administer and oversee ECM benefits, identifying members in each of the ECM target populations and assigning them to “ECM providers” responsible for conducting outreach and for coordinating and managing care across a broad spectrum of physical, behavioral, and social service providers. ECM services will be community-based, with high-touch, on-the-ground, face-to-face, and frequent interactions between members and ECM providers.
• In Lieu of Services (ILOS), which are cost-effective, health-supporting services that may be substituted for existing State Plan–covered services to reduce hospitalization and institutionalization, reduce cost, and address underlying drivers of poor health. DHCS will allow 14 ILOS categories, including housing transition and navigation services, respite care, day habilitation programs, and nursing facility transition support to an assisted living facility or a home. MCPs may choose which ILOS to cover, in which counties, and to which members.

The ECM and ILOS programs will engage a broad set of MCPs, providers, county agencies, and community-based organizations. Many of these organizations do not currently interact extensively with the health care system and have limited information technology capacity. Nevertheless, their participation in the program and ability to share and use administrative, health, and social service information will be vital in carrying out ECM and ILOS program functions including:

• ECM member identification, review, and authorization, where MCPs will identify target ECM populations by compiling and analyzing data and information received from counties, providers, members, and others.
• ECM assignment and member engagement, where MCPs will assign members to an ECM provider based on their previous provider relationships, health needs, and known preferences, and ECM providers will use available information to reach and engage members eligible for the ECM benefit.
• ECM care plan development, sharing, and use, where ECM providers will develop care plans using data acquired from the MCP, the member, and other sources, and make the care plan available for use by a member’s care team.
• ECM care coordination and referral management, where ECM providers will support coordinated and transitional care, and engage MCPs’ referral networks for community and social services, including ILOS.
• ECM and ILOS billing and encounter reporting practices, where ECM and ILOS providers will record and report services rendered to MCPs, and MCPs will report complete and accurate encounters of all services provided by contracted ECM and ILOS providers to DHCS.
• ECM and ILOS quality measure and performance reporting, where MCPs will report DHCS-specified quality and performance metrics to demonstrate ECM and ILOS program impact on member health, well-being, and costs.
• ILOS needs assessment and referral management, where MCPs and ECM and ILOS providers will identify members requiring ILOS benefits, and MCPs, primary care physicians, or ECM providers will connect members to ILOS through a closed-loop referral process.

This implementation road map identifies data, data exchange, and information system barriers to implementing ECM and ILOS program functions, and offers a set of recommendations and actions that policymakers, government agencies, MCPs, and providers can take to resolve them. As the road map describes, whole-person approaches to care are whole-community approaches to care that require all parties to step outside of their traditional boundaries to provide a level of collaboration and coordination that addresses drivers of health.

Road map recommendations each address three categories of data-sharing barriers and the steps necessary to mitigate them, including:

• Regulations and policies to facilitate safe and secure information sharing
  
• Technical infrastructure and standards to support the efficient collection, exchange, and use of member information
  
• Financing, contracting, and operations, where aligning incentives, contracting, and tactics is crucial to institutionalizing the programs and ensuring their long-term success

Each recommendation speaks to these barriers while offering a proposed set of actions, including their sequence and timing for implementation. Road map development was informed by over two dozen interviews and an advisory group composed of DHCS, MCPs, county agencies, providers, and community-based organizations.

About the Authors

Jonah Frohlich, MPH, is managing director; Kevin McAvey, MA, MPP, is director; and Jonathan DiBello, MPH, is consultant at Manatt Health Strategies, a consulting subsidiary of Manatt, Phelps & Phillips. Manatt Health Strategies combines legal excellence, firsthand experience in shaping public policy, strategy insight, and deep analytic capabilities to provide professional services to the full range of health industry players.