Active

Community-Led Integration Pilot Charter

Enhanced Care Management Embedded in Acute Care Settings

In partnership with the Institute on Aging, Tipping Point, and the Safety Net Institute, a pilot to embed a case manager employed by a Community-Based Organization in hospitals to support enrollment into CalAIM Enhanced Care Management (ECM) and reduce ER and hospital utilization for patients with multiple chronic conditions.

Background

Medi-Cal members typically have several complex health conditions involving physical, behavioral, and social needs. Members with complex needs must often engage several delivery systems to access care, including primary and specialty care, dental, mental health, substance use disorder treatment, and long-term services and supports. More than half of Medi-Cal spending is attributed to the 5 percent of members with the highest-cost needs. Launched in 2022, CalAIM Enhanced Care Management (ECM)is a statewide Medi-Cal benefit available to select members with complex needs. Enrolled members receive comprehensive care management from a single lead care manager who coordinates all their health and health-related care, including physical, mental, and dental care, and social services. Enhanced Care Management makes it easier for members to get the right care at the right time in the right setting and receive comprehensive care that goes beyond the doctor’s office or hospital.

Proposal

In partnership with the Institute on Aging, the Impact Accelerator Community-Led Integration Pilot will explore the impact of embedding a case manager employed by a Community-Based Organization in hospitals to support enrollment into CalAIM Enhanced Care Management (ECM) and reduce ER and hospital utilization for patients with multiple chronic conditions using a trauma-informed internal referral methodology. The Impact Accelerator will leverage the network of safety-net providers, health plans, and researchers to spread best practices and assist with scaling to additional locations and community-based
organizations.

DHCS estimates that 15 million Californians, or approximately 40% of the population, are enrolled in MediCal in any given month and that 5% of those members (750,000) would be eligible to receive Enhanced Care management services, with some Managed Care Plans estimating as high as 7%. Although enrollment has increased since 2022, growth has been slow with approximately 178,000 members (1.2% )of MediCal members currently receiving ECM benefits, with rates varying across regions, managed care plans, and populations of focus. Factors that limit utilization include limited experience offering non-medical services by health plans, community-based organizations with less familiarity working with managed care plans, the capacity of providers to start a new service line, and poor conversion rate with outreach efforts.

Evaluation of successful methods for ECM enrollment by RAND, 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. In-house referrals, beginning with a trusted clinician describing the service and answering questions, were more successful than receiving calls generated from managed care plan eligibility lists.

The Institute on Aging (IOA), an ECM provider, employs care management staff and receives per-member-per-month
payments for enrolled MediCal members who qualify for ECM services. In collaboration with hospitals and managed care
plans, IOA’s care management staff are embedded in hospitals to receive warm hand-off referrals from trusted hospital
clinicians and staff. Patients who meet program eligibility and are interested are enrolled for ongoing ECM comprehensive
care management and care coordination by IOA. This collaborative approach leverages the trusted relationship of the
hospital clinician and staff to enroll the highest risk MediCal patients into ECM and utilizes sustainable revenue from ECM
to support staffing that is scalable by the CBO.

Phase I: Soft Launch (Q3-4 2025)

CPMC Davies Campus and Zuckerberg General – Summer 2025
Sutter Van Ness and Mission Bernal – September 2025
UCSF St. Mary’s November 2025
Results:
- 125 ECM enrollments in 4 months.
- 45% referral conversion rate compared to 15% baseline from managed care plan eligibility lists.

Phase II: Scale and measurement (Q1-2 2026)

Scale to Stanford, Safety-net hospitals
Additional health plans
Enroll other CBOs with a similar enrollment model, if available.
Data acquisition and formal research planning

Phase III: Evaluation and Measurement (Q3-4 2026)

Tipping Point evaluation of high-risk older adults with risk of homelessness
UCSF evaluation (details needed)
Stanford

Tipping Point, UCSF, Stanford researchers, in collaboration with other academic partners as needed, will lead the measurement
and evaluation of the pilot. Evaluation considerations:

Reductions in length of stay throughout the post-acute continuum.
Increased discharge planning and care management capacity
Higher referral conversion rates; expedited ECM authorizations and enrollment
Opportunity to integrate ECM into other SDOH Screening or Care Transitions initiatives
Evaluation of a subset of older adults at risk of homelessness (Tipping Point).

Reducing the administrative burden for MediCal enrollment and redetermination is critical to protect health care
access for low-income Californians and for the financial viability of the safety-net system of care.
Creates a multi-sector solution that allows for trust-building and network development across the safety-net and
community-based organizations.
Safeguards ambulatory access for eligible patients to reduce liability for overburdened acute care systems.

Our Role

Convene stakeholders and coordinate activities.
Support research and measurement activities.
Project planning and communication.
Network connector, TA support, shared learning across participating organizations and partners.
Fund development.

Stakeholders

Community-Based Organization: Institute on Aging
• MCOs: San Francisco Health Plan, Health Plan of San Mateo
• Partners: Sutter, Stanford Medicine, UCSF, Safety-Net Institute
• Research: Tipping Point, Stanford, UCSF