Key Findings and Recommendations for Implementation of California Advancing and Innovating Medi-Cal (CalAIM) Services

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Adverse childhood experiences (ACEs), such as abuse and neglect, lead to toxic stress that disrupts healthy development and increases susceptibility to numerous health conditions. This has significant economic costs and disproportionate impacts on low-income and minority populations. The ACEs Aware initiative is a groundbreaking effort by the state of California to improve population health and promote health equity through screening for and responding to ACEs and toxic stress throughout the state's Medi-Cal system.

The PRACTICE Initiative and Evaluation

Preventing and Responding to ACE-Associated Health Conditions and Toxic Stress in Clinics through Community Engagement (PRACTICE), the third round of ACEs Aware community grants, focused on supporting teams of primary care clinics, community-based organizations (CBOs), and managed care plans (MCPs) that partnered to implement new California Advancing and Innovating Medi-Cal (CalAIM) services. The grants have funded 25 teams in 15 California counties to identify gaps in care, leverage existing and new funding, and deploy sustainable services, supported by an 18-month learning collaborative offering technical assistance, training, resources, and peer-to-peer learning. RAND researchers' evaluation of PRACTICE included an in-depth investigation of nine teams that were early adopters and successfully implemented one or more of the four key CalAIM services (adult enhanced care management [ECM], pediatric ECM, the community health worker [CHW] benefit, and dyadic services). In this brief, the authors present the highest-impact findings and recommendations from this in-depth exploration of the development and implementation of CalAIM services, organized into four domains.

Domain 1: Connecting Patients to CalAIM Services

Teams made progress planning for and implementing the new CalAIM services that aligned with the PRACTICE goal of improving care for individuals who have experienced ACEs, ACE-associated health conditions, and toxic stress. The RAND research team's in-depth exploration of the four key CalAIM services surfaced important learnings about the process of connecting patients to these services.

Findings

• A trauma-informed approach that builds on the trust and connection that patients and providers develop over time is the most effective way to connect patients with the services they need.
• Clinicians were most successful at referring patients through in-house referrals, particularly for ECM (see Figure 1). These in-house referrals began with a trusted clinician describing the service and answering patients' questions. These providers then either introduced patients to ECM providers in person or arranged for a provider to contact them.
• Referrals that involved MCPs identifying patients who were potentially eligible for ECM services via eligibility lists were less effective because patients received cold calls from an unfamiliar person offering services they were not aware of or because the lists were inaccurate.
• Trauma-informed strategies, such as maintaining an open-door policy for patients who initially decline services, normalizing the receipt of services to reduce any associated stigma, and hiring bilingual staff to bridge language barriers, were also effective in engaging patients in services.

Effective Approach

In-house referral leads to a trusted clinician describes service then there is either a virtual handoff or a warm handoff. The referral outcome is either patient is enrolled in the ECM or not enrolled in ECM.

Ineffective Approach

MCP referral with or without a letter from MCP describing services leads to a cold call offering services. The referral outcome is either patient is enrolled in the ECM or not enrolled in ECM.

Recommendations

For the California Department of Health Care Services (DHCS) and MCPs

• Have referrals to CalAIM services come from a trusted provider with whom patients already have a trusting relationship or who is well positioned to be able to develop a trusting relationship.
• Transition away from plan-generated ECM eligibility lists to a more streamlined process for connecting patients to services that ideally involves a trusted provider.

For Clinics andCBOs

• Identify current patients eligible for CalAIM services and target outreach and engagement toward them.
• Have trusted providers introduce services and make referrals and handoffs.
• Use flexible and tailored approaches to patient engagement, such as normalizing the need for support and offering services at multiple points.

Domain 2: Implementing the ECM Model of Care and Reimbursement Rates

The RAND research team's detailed examination of the ECM benefit found several issues specific to its implementation and sustainability.

Findings

• Because current ECM reimbursement rates may not cover the total costs of services, clinics continue to use other funding to cover the costs of providing ECM.
• MCPs are still developing processes related to authorization and other aspects of ECM, which can burden clinics implementing those services.
• Patients and providers faced challenges and frustration when graduating from ECM because patients were suddenly unable to access supports they had come to rely on.
• ECM providers perceived a misalignment among the severity of patient conditions, the level of provider expertise needed, and ECM reimbursement rates.

Recommendations

For DHCS and MCPs

• Standardize ECM eligibility and authorization policies to help MCPs develop uniform requirements.
• Streamline the ECM authorization process by having MCPs accept provider assessments of ECM eligibility.
• Examine alignment between the ECM patient acuity level, the level of staff required for ECM, and the ECM reimbursement rate.

For MCPs

• Consider increasing ECM reimbursement rates to more accurately reflect the ECM acuity level and necessary staffing.
• Strengthen the ECM provider network by contracting with trusted agencies that are specific to each population of focus (i.e., a defined category of members eligible to receive ECM).

For Clinics and CBOs

• For smaller CBOs, consider forming or joining an intermediary contracting entity to centralize contracting, training and supervision, referrals, documentation, and billing as a way to achieve financial sustainability for ECM.
• Focus on identifying and enrolling current ECM-eligible patients who already have trusting relationships with the providers to facilitate engagement in services and increase the financial viability of providing them.
• Plan for services needed by lower-acuity patients — those who do not meet ECM eligibility criteria and those who have graduated from ECM.

Domain 3: Providing the Community Health Worker and Dyadic Services Benefits

The research team's review of the CHW and dyadic services benefits uncovered some issues with the implementation and long-term sustainability of these services.

Findings

• CBOs and non–Federally Qualified Health Centers (non-FQHCs) faced major challenges in contracting for the CHW benefit because of inadequate reimbursement rates and unclear certification requirements.
• Clinics and CBOs adopting a co-location model for CHW services encountered difficulties in MCP contracting and billing under this model.
• FQHCs faced challenges providing dyadic services because of a lack of clarity from DHCS about reimbursement for this benefit.

Recommendations

For DHCS

• Consider strategies for increasing CHW benefit reimbursement rates.
• Finalize CHW certification guidance to facilitate contracting.
• Offer clear guidance on payment arrangements for co-located staff to ensure consistency across MCPs.
• Clarify payment policies to FQHCs for dyadic services.

For MCPs

• Consider increasing the CHW benefit reimbursement rate as a way to improve health outcomes — for example, improving Healthcare Effectiveness Data and Information Set scores associated with DHCS's Bold Goals, which set targets for health care access and quality improvement in several areas.^[1]

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Domain 4: Understanding the Impact of CalAIM Services on Patients, Caregivers, and Providers

Despite challenges implementing and sustaining key CalAIM services, it is important to elevate the voices of patients and caregivers who received new CalAIM services, as well as frontline providers referring patients to and providing CalAIM services. Their voices illustrate the powerful positive impact of these services and the importance of continuing to make progress.

Findings

• Trauma-informed care approaches (e.g., referrals to services from trusted providers, warm handoffs to new service providers) helped build trusting relationships between patients and providers.
• Patients, their caregivers, and providers reported that CalAIM services substantially improved the health and well-being of patients and their caregivers.
• CalAIM services reduced clinicians' stress levels by providing support for patient care.

Conclusion

The impact of the new CalAIM services has transformed how vulnerable patients receive essential support. The RAND research team's in-depth exploration of the implementation of these key CalAIM services showed that a trauma-informed approach based on trust and connection can allow these programs to succeed and improve patients' lives. Patients and caregivers reported substantial positive impacts of these services on their health and well-being, and the services have reduced the burdens on providers who are already shouldering significant responsibilities for high-needs patients. Although this work can be challenging and burdensome for clinics and CBOs, it is worth continuing because it is improving the care of vulnerable populations in California.

Notes

• [1] DHCS CalAIM, "CalAIM Bold Goals: 50x2025," webpage, undated. As of August 13, 2024: https://calaim.dhcs.ca.gov/pages/bold_goals

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Topics

• California
• Childhood Trauma
• Health Care Education and Training
• Health Care Program Evaluation
• Primary Care