Over half of Medi-Cal spending is attributable to the 5 percent of enrollees with the highest-cost needs.
Medi-Cal enrollees typically have several complex health conditions involving physical, behavioral, and social needs.
Enrollees with complex needs must often engage several delivery systems to access care, including primary and specialty care, dental, mental health, substance use disorder, and long-term services and supports.
California introduced community-based care management with promising results in many counties through the Health Homes Program and Whole Person Care Pilots. CalAIM is California’s first statewide effort to address complex care management. For more follow this link Review of Provider Roles & Requirements for ECM & ILOS.
Frank has struggled with opioid addiction while
living on the streets of San Francisco for the past
four years. Frank visited the emergency
department seven times in the last two years
because of overdoses and he returns to the
streets after brief stays in shelters. In 2020,
Frank contracted COVID-19 and continues to
experience long-term symptoms. CalAIM’s
Enhanced Care Management connects Frank with
a care manager. They can meet at a nearby food
bank to make plans for him to see his mental
health provider to get his medication adjusted,
and to follow up with his primary care doctor. The
case manager can also connect Frank to a local
Community Supports provider who will help him
secure safe, supportive housing.
CalAIM will improve Medi-Cal for people with complex needs and who are facing difficult life and health circumstances. It is focused on breaking down the traditional walls of health care – extending beyond hospitals and health care settings into communities. As a key part of CalAIM, Enhanced Care Management will be a new statewide Medi-Cal benefit available to “populations of focus,” including:
Benefits of the Enhanced Care Management pilots expanded to a statewide program.
During the pilots, emergency department and inpatient utilization rates decreased, and indicators of preventative care and engagement increased.
Justice-involved individuals saw a 29 percent improvement
in control of high blood pressure. In 2022, about 95,000 Medi-Cal enrollees will be able to use Enhanced
Care Management, including those experiencing homelessness, high utilizers, and adults with serious
mental illness or substance use disorders. California expects to see positive impacts on outcomes and
total costs when comprehensive, community-based care coordination is available to those with the highest
needs across the state.
Our CHW Services program aligns with Medi-Cal community health worker (CHW) services, pursuant to 42 CFR Section 440.130(c), as preventive services and on the written recommendation of a physician or other licensed practitioner of the healing arts within their scope of practice under state law.
CHW services may address issues that include, but are not limited to, the control and prevention of chronic conditions or infectious diseases; mental health conditions and substance use disorders; need for preventive services, perinatal health conditions; and reproductive health; environmental and climate-sensitive health issues; child health and development; oral health; aging; injury; domestic violence; and violence prevention.
Definition:
Community health worker (CHW) services are preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health.
Our Community health workers may include individuals known by a variety of job titles, including promotores, community health representatives, navigators, and other non-licensed public health workers, including violence prevention professionals, with the qualifications.
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Financial well-being is a condition wherein a person can fully meet current and ongoing financial obligations, can feel secure in their financial future, and is able to make choices that allow them to enjoy life.