CalAIM (California Advancing and Innovating Medi-Cal) is a multi-year initiative by the California Department of Health Care Services (DHCS) to improve the health outcomes and quality of life for Medi-Cal members. The enhanced care management services of CalAIM are designed to provide more personalized, coordinated, and effective care to Medi-Cal beneficiaries with complex needs.

The seven services of CalAIM enhanced care management are:

1) Outreach and Engagement

Outreach and engagement are the first steps in identifying and engaging Medi-Cal beneficiaries with complex needs who may benefit from enhanced care management services. The goal of outreach and engagement is to establish trust and build relationships with eligible members, and to educate them about the available resources and services that can support their health and well-being.

The outreach and engagement services include:

Member identification: Identifying members who may benefit from enhanced care management services based on their medical, behavioral, and social needs.

Member outreach: Contacting identified members through various channels, such as phone calls, letters, and in-person visits, to inform them about the enhanced care management services available.

Member education: Educating members about how enhanced care management services can help them achieve their health goals.

Here are some tips for effective outreach and engagement:

  • Be culturally responsive. Tailor your outreach and engagement efforts to the needs of the population you are serving.
  • Be patient. Building relationships with members and engaging them in the ECM program may take time.
  • Be persistent. Don’t give up on members who are hesitant to participate.
  • Be creative. Use a variety of outreach and engagement methods to reach members.
  • Be data-driven. Track your outreach and engagement efforts to see what is working and what is not.

2) Comprehensive Assessment and Care Management Planning

Comprehensive Assessment and Care Management Planning is another critical component of the CalAIM enhanced care management services. This service involves conducting a thorough assessment of each enrolled member’s medical, behavioral, and social needs and developing a personalized care plan that addresses those needs.

Health and SDOH assessment: Conducting a comprehensive health risk assessment to identify each member’s medical, behavioral, and social needs, as well as any potential barriers to care.

Person-Centered care planning: Developing a personalized care plan that addresses each member’s unique needs and preferences, as well as their health goals and priorities.

Care plan review and updating: Regularly reviewing and updating the care plan to ensure that it remains relevant and effective, and adjusting the plan as needed to address any changes in their health status or needs.

Here are some tips for comprehensive assessment and care management:

  • The member should be involved in all aspects of the process, from the assessment to the development of the care plan.
  • Leverage technology such as whole-person care management and telehealth tools to improve care coordination and communication among care team members, as well as increase access to care for patients.
  • Foster collaboration among care team staff

3) Enhanced Coordination of Care

The lead care manager is responsible to work with the member and their providers to coordinate all of their care, including primary care, specialty care, mental health care, substance use disorder treatment, and long-term services and supports. This includes sharing relevant health information among different providers and organizations to promote care coordination and reduce duplication of services.

Develop shared care plans: Developing shared care plans that are accessible to all members of the care team can improve communication, promote collaboration, and ensure that all providers are working towards the same goals.

Hold regular care team meetings: Regular care team meetings can facilitate communication, foster collaboration, and provide an opportunity for providers to discuss complex cases and share best practices.

Use data to monitor performance and identify areas for improvement: Collecting and analyzing data on care coordination metrics such as hospital readmissions, emergency department visits, and patient satisfaction can help identify areas for improvement and inform quality improvement initiatives.

4) Health Promotion

Health promotion is designed to help members make healthy choices and improve their overall health.

There are a number of different ways that health promotion is incorporated into CalAIM ECM. Some of the most common approaches include:

  • Education: Care managers provide enrollees with education about health-related topics, such as diet and nutrition, physical activity, and chronic disease prevention.
  • Support: Care managers provide enrollees with support and encouragement to make changes to their lifestyle. This may include helping them to find healthy recipes, set up exercise routines, or find a support group.
  • Enhancement: Care managers help enrollees to develop skills and confidence to take control of their health. This may include teaching them how to read their medication labels, how to manage their chronic conditions, or how to advocate for themselves in the healthcare system.
  • Empowerment: Care managers help enrollees to feel empowered to make healthy choices. This may include helping them to set goals, develop a plan to achieve their goals and track their progress.

5) Comprehensive Transitional Care

Comprehensive Transitional Care is designed to support members who are transitioning from one care setting to another, such as from a hospital to home, to ensure a seamless and safe transition.

Transitional care planning: Developing a comprehensive care plan that addresses the member’s medical, behavioral, and social needs during the transition period.

Medication management: Ensuring that members have access to their medications, understand how to take them, and have the necessary support to manage any potential side effects or interactions.

Follow-up care: This involves ensuring that members receive appropriate follow-up care, such as post-discharge visits, to monitor their health status and ensure that they are recovering as expected.

6) Member and Family Supports

This service recognizes the critical role that family members and caregivers play in supporting members with complex health needs.

This service involves documenting the member’s chosen caregiver(s) or family/support person and ensuring that the member and chosen family/support persons, including guardians and caregivers, are knowledgeable about the member’s conditions. ECM lead care manager serves as the primary point of contact for the member and chosen family/support persons.

Caregiver support: Providing education, training, and help to family members and caregivers who provide care to members.

7) Coordination of and Referral to Community and Social Support Services

This service aims to address the social determinants of health that impact the health and well-being of ECM members.

Referral to community-based organizations (CBOs): Connecting ECM-enrolled members with CBOs that can provide resources and services to address social determinants of health, such as transportation, housing, food assistance, and legal services.

Care coordination with CBOs: Coordinating care between healthcare providers and CBOs to ensure that Medi-Cal members receive integrated care that addresses their medical and social needs.

Benefit enrollment: Helping ECM members enroll in programs such as CalFresh, CalWORKs, and others to access resources and benefits that can improve their health and well-being.

Sprite Health offers a highly comprehensive digital platform that enables the efficient management of all ECM requirements in a single place. Our solution is purposefully designed to cater to the specific needs of the CalAIM ECM/CS initiative.

Connect with us to learn how you can enhance outreach efforts, streamline care planning and coordination, and fosters a data-driven and outcome-oriented approach that advances equity, and clinical outcomes.