The authors evaluated the Preventing and Responding to ACE-Associated Health Conditions and Toxic Stress in Clinics through Community Engagement (PRACTICE) collaborative. PRACTICE funded partnerships between primary care clinics and community-based organizations to work with managed care plans. The evaluation identified promising practices for implementing and sustaining CalAIM services and evaluated activities and progress of 25 PRACTICE teams.

Developing Services and Workforce in Response to the California Advancing and Innovating Medi-Cal (CalAIM) Initiative

Learnings from Primary Care Clinics and Their Partners in the ACEs Aware PRACTICE Collaborative

Peggy G. Chen, Dana Schultz, Graham DiGuiseppi, Kortney Floyd James, Wendy Hawkins, Chloe Gomez, Stacey Yi, Gabriela Alvarado, Ingrid Estrada-Darley, Priya Gandhi, et al.

ResearchPublished Oct 11, 2024

The ACEs Aware initiative is a groundbreaking effort by the state of California to improve health for all and promote health equity through screening for and responding to adverse childhood experiences (ACEs) and toxic stress. The authors identified promising practices for implementation and sustainability of four key California Advancing and Innovating Medi-Cal (CalAIM) services to fill gaps in care and address ACE-related health disparities: (1) adult enhanced care management (ECM), (2) pediatric ECM, (3) the community health worker (CHW) benefit, and (4) dyadic services. They also evaluated the entire Preventing and Responding to ACE-Associated Health Conditions and Toxic Stress in Clinics through Community Engagement (PRACTICE) collaborative, including activities and progress across all 25 PRACTICE teams.

The findings show that despite being in early developmental phases, numerous clinics effectively integrated adult and pediatric ECM and were able to bill and secure reimbursement via CalAIM benefits. However, clinics and community-based organizations (CBOs) were still making progress on billing and reimbursement for CHW and dyadic benefits under CalAIM. Both patients and providers cited important benefits of key CalAIM services, with patients feeling empowered, supported, and hopeful and clinicians experiencing lower stress levels and improved ability to provide care.

Teams in the PRACTICE collaborative made substantial progress implementing CalAIM services and developing an effective workforce to help respond to toxic stress. Teams enhanced their ability to provide trauma-informed care, bolstered their capacity for ACE screening, trained more than 3,200 staff with ACEs Core Aware Training, and improved their ability to provide referrals to services.

Key Findings

  • Patients and their families appreciated the CalAIM services and felt supported, empowered, and hopeful after using them.
  • Clinicians valued CalAIM services, reporting that the support lowered their own stress and helped them provide better, more-focused care.
  • Robust training that combined coursework with on-the-job training was critical for preparing staff to deliver services.
  • Services worked well when integrated into clinics' electronic health records, workflows, and referral systems.
  • A trauma-informed approach to referrals, utilizing trusted clinicians, is the most effective approach for engaging patients. Other effective strategies included co-locating providers, using bilingual staff, offering phone interactions when in-person visits were impractical, keeping options open even when services were initially declined, and normalizing service usage.
  • Implementation of the CHW benefit has been hampered by a low reimbursement rate, a lack of clarity about certification requirements, and Federally Qualified Health Centers' (FQHCs') inability to bill for the CHW benefit.
  • There is a perceived mismatch between the patient acuity level required for ECM eligibility and the level of provider that can be supported with ECM reimbursement. There is also a service gap for lower-acuity patients who do not meet eligibility criteria and those who have graduated from ECM.
  • It can be challenging to identify the right point of contact for initiating contracting with managed care plans (MCPs). Even once contracted, MCPs can introduce additional strain and administrative burden to clinics implementing CalAIM services because of inaccuracies in referral lists; delays in obtaining authorization and approval for services; and differences in policies, criteria, and reporting requirements.

Recommendations

  • Building and expanding the workforce: Clinics and CBOs should develop relationships with colleges and universities to create a pipeline, prioritize staff with community familiarity and relevant skills, and provide field-based training and support.
  • Implementing CalAIM services: Clinics and CBOs should prepare for an iterative implementation process, customize EHRs and documentation, and plan for "step-down" programs for patients who are not ECM-eligible but still need support.
  • Patient engagement: Clinics and CBOs should have clinicians introduce services and employ warm or virtual handoffs to build on existing trusted relationships and negotiate with MCPs to minimize cold call referrals and improve referral accuracy.
  • Billing and reimbursement: Clinics and CBOs should engage billing teams early to anticipate and address potential bottlenecks and prepare to financially support complex programs for high-needs patients, such as the key CalAIM services, until they reach financial viability.
  • State policymakers should encourage MCPs to collaborate with clinics and CBOs on approaches for identifying patients who may benefit from a referral, provide uniform guidance on eligibility and reimbursement to minimize variation across MCPs, and streamline approval processes by encouraging MCPs to accept referring providers' assessments of ECM eligibility.
  • State policymakers should provide guidance on matching ECM reimbursement rates with appropriate staffing levels, develop financial feasibility methods for FQHCs to provide and be reimbursed for CHW services, and examine increasing the reimbursement rate for the CHW benefit.
  • State policymakers should finalize certification requirements for CHW services to support billing and reimbursement and clarify payment policies for dyadic services in FQHCs.

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Chen, Peggy G., Dana Schultz, Graham DiGuiseppi, Kortney Floyd James, Wendy Hawkins, Chloe Gomez, Stacey Yi, Gabriela Alvarado, Ingrid Estrada-Darley, Priya Gandhi, and Nicole K. Eberhart, Developing Services and Workforce in Response to the California Advancing and Innovating Medi-Cal (CalAIM) Initiative: Learnings from Primary Care Clinics and Their Partners in the ACEs Aware PRACTICE Collaborative. Santa Monica, CA: RAND Corporation, 2024. https://www.rand.org/pubs/research_reports/RRA2152-1.html.
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This research was funded by the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) through a contract with the California Department of Health Care Services and carried out within the Quality Measurement and Improvement Program in RAND Health Care.

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