NOVEMBER 2023 PERSPECTIVES FROM THE FIELD by Claudia Boyd-Barrett CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management A first-of-its-kind convening in October brought Above all, MCPs and ECM providers are tasked with together Medi-Cal managed care plans, figuring out how to effectively reach the Medi-Cal health care providers, and community-based members that ECM is intended to help and deploy organizations from across the state to swap insights, the benefit in a way that truly enhances these patients' share innovations, and develop ideas for boosting care and wellbeing. uptake of Medi-Cal's ambitious new Enhanced Care Management benefit. The two-day October meeting, titled CalAIM Implementation Share & Learn, presented an inaugural Enhanced Care Management (ECM) is foundational opportunity for MCPs and ECM providers from various to California's efforts to transform Medi-Cal under regions to discuss these challenges collectively, listen the California Advancing and Innovating Medi-Cal to each other's perspectives, and engage creatively in (CalAIM ) initiative.1 Launched in 2022, the goal of identifying solutions. Organized by CalOptima Health ECM is to ensure Medi-Cal members with complex and Health Plan of San Mateo, facilitated by the Center needs receive comprehensive care and support for Care Innovations, and sponsored by CHCF, the by assigning a lead care manager to coordinate event incorporated hands-on, dialogue-based activi- all their health and health-related care, including ties that encouraged idea sharing and collaboration. social services. Kelly Bruno-Nelson, executive director of Medi-Cal and As with most major initiatives, the implementation CalAIM with CalOptima Health, said that while there of ECM is challenging. Managed care plans (MCPs) have been other CalAIM conferences organized by must recruit and partner with a wide range of pro- the Department of Health Care Services (DHCS), these viders, many of whom have never worked within the tend to follow a more traditional, didactic approach. Medi-Cal system before. Together they must cre- ate new workflows, build mutual understanding and trust, and hire and train qualified staff to ensure a suf- ficient workforce. About the Perspectives from the Field Series As California's Department of Health Care Services "It wasn't until I began collaborating with other administers changes to the Medi-Cal program, es- ECM providers outside of my organization that pecially those that are part of the CalAIM initiative, CHCF is intermittently publishing short reports that things began to really click." highlight the perspectives of those in the field who -Belén Arangure, ECM program manager, are implementing the changes. These "Perspectives Northeast Valley Health Corporation from the Field" seek to inform policymakers and other health care leaders about insights and experi- ences from people on the ground who work directly with patients. Inspired by networking practices she engaged in dur- David Hoang, a CHW and case manager with Asian ing her previous role as president of the nonprofit Health Services in Oakland, said he attended the National Health Foundation, she wanted to create an event hoping to learn how other providers are opportunity for the organizations involved in the ECM approaching common challenges with ECM imple- rollout to interact and collaborate. Organizers also mentation, such as how to design their workflows, said they hoped the structure would encourage more get training, and deal with new administrative open and honest discussion among attendees, who requirements. may feel less comfortable being candid in the pres- ence of state regulators. "We developed a workflow, but it wasn't easy, we had to start from scratch," he said of his organization. "I "Never once has there been an effort to bring the like speaking with other folks to learn about their pro- group together to build community, build colleagues grams and what's their best approach to solve issues… and space for us to be transparent, honest, learn from then it's easier for me down the road." each other, share what's working, what's not working," Bruno-Nelson said. "That's what this is." Belén Arangure, ECM program manager with Northeast Valley Health Corporation, a Federally In addition to CalOptima and Health Plan of San Qualified Health Center in Los Angeles, said she Mateo, participating health plans included Anthem wanted to network with ECM providers from other Blue Cross, Blue Shield Promise, Central California counties and gather new ideas to advocate for in her Alliance for Health, San Francisco Health Plan, local setting - especially those related to streamlin- HealthNet, Inland Empire Health Plan, Partnership ing documentation and data reporting. This has been Health Plan of California, and Santa Clara Family particularly challenging for providers in LA County Health Plan. MCPs met on the first day of the con- where there are four MCPs, all with different require- vening, and then joined in discussions with providers ments, she said. on the second day. Providers present on the second day included four social service organizations and 15 During the first year of ECM implementation, Arangure health care organizations, among them representa- experienced a sense of isolation and frustration. There tives from Federally Qualified Health Centers and were many gray areas in regard to billing, ongoing community clinics, mental health and substance use program deliverables, and reporting across different disorder treatment providers, organizations serving MCPs, which contributed to a limited understanding people experiencing homeless and other specific of the program within her organization. Since then, populations, and community health workers. she's been actively seeking out other ECM providers in her community to talk to. "The uptake of [ECM] services has been slow "It wasn't until I began collaborating with other ECM and in much lower numbers than I think providers outside of my organization that things began people had hoped and expected. There are to really click," she said. processes in place to get referrals to enhanced care management, and it's an 'if you build it, they will come' [approach], and they're not really coming." -April Watson, director of learning, Health Plan of San Mateo CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 2 The ECM Journey so Far "If you just wait for a patient to go to DHCS requires all MCPs to implement ECM. Along with the ER, hope that the emergency room 14 optional services known as Community Supports, provider generates a diagnosis code that it's the first new Medi-Cal benefit introduced under CalAIM, and targets the Medi-Cal members with the flags the managed health care plan to the greatest needs.2 These members typically have mul- patient's status as homeless, that is a very tiple health and social needs and engage with several passive approach for engaging with people delivery systems to access care. experiencing homelessness. You need to do By offering comprehensive care coordination and outreach in the community." engaging with members wherever they are - whether -Benjamin Kaska, street medicine physician assistant that's the street, the doctor's office, or at home - ECM and regional manager, Healthcare in Action aims to make accessing care a seamless experience for these individuals that is more responsive to their In July, DHCS rolled out several changes to address full spectrum of needs. these and other issues, which plans are currently in the process of implementing. To implement ECM, MCPs must establish and train networks of community-based providers to deliver "The uptake of [ECM] services has been slow and in the benefit in the regions the plan serves. DHCS has much lower numbers than I think people had hoped also instructed them to negotiate their own rates and expected," said April Watson, director of learning with providers, identify and assign members to ECM at Health Plan of San Mateo. "There are processes in providers, oversee service delivery, and collect per- place to get referrals to enhanced care management, formance data. and it's an 'if you build it they will come' [approach], and they're not really coming." Counties have gradually extended the benefit to designated populations of focus, following a sched- "If you just wait for a patient to go to the ER, hope ule provided by DHCS.3 The benefit will go live for that the emergency room provider generates a diag- the final groups – people transitioning from incar- nosis code that flags the managed health care plan ceration and birth equity populations of focus - in to the patient's status as homeless, that is a very pas- January 2024. sive approach for engaging with people experiencing homelessness," said Benjamin Kaska, a physician While the rollout has marched ahead as scheduled, assistant and regional manager with street medicine ECM's implementation and uptake have been bumpy provider Healthcare in Action. "You need to do out- and uneven. For starters, MCPs are still working on reach in the community." building their ECM provider networks, which bring together a wide range of community-based entities A survey of almost 1,200 CalAIM implementers experienced at providing culturally sensitive care man- between July 21 and September 12, 2023, found that agement to the population of focus they serve. around half of respondents believed the program was improving care for members on the ground. However, In addition, while over 109,000 members received the experience of implementation and its effective- ECM in 2022, the number of people actively enrolled ness varied by sector. Almost 80% of MCPs rated in the benefit declined over the course of 2022 – a implementation as very or somewhat effective, but trend that is mirrored by Community Supports. that percentage slid to as low as 36% among pro- viders, with the lowest ratings coming from those in behavioral health. California Health Care Foundation www.chcf.org 3 Barriers to Implementation community organizations. This means MCPs may not recognize CBOs' differences in structure, and Enrollment capacity, communication, credentialing, and docu- Bruno-Nelson and her colleague, Danielle Cameron, mentation practices, making it more difficult for director of program development for CalAIM at MCPs to build rapport with these organizations. CalOptima Health, said MCPs and providers face A Insufficient empathy. Also affecting rapport is a several internal and external barriers. Like Bruno- lack of empathy among MCP staff toward CBOs Nelson, Cameron previously worked at the National engaging with the Medi-Cal system for the first Health Foundation, a community-based organiza- time, Bruno-Nelson said. tion (CBO) in Los Angeles known for recuperative care programs. A Time pressure from above. MCPs feel pressure from DHCS to launch ECM quickly. But state expec- The executives said their experiences on the provider tations don't align with very real limitations on the and now MCP sides have given them insights into the ground, Cameron said. challenges both face when it comes to ECM imple- mentation. These include: "The reality is the field wasn't ready," said Bruno- Nelson. "There's so much money being infused and, while we're grateful for those dollars, it doesn't imme- Challenges for CBOs: diately fix the problems. Non-profits have to have the A Lack of experience as Medi-Cal providers. Many time and training to be able to increase the capacity to CBOs joining the ECM system previously relied on the level that we need." grants and fundraising to operate, often on a shoe- string budget. They have neither the systems in place to do medical billing nor the staffing capacity Journey Mapping Ideal to handle it. Solutions A Not enough staff, facilities, or training to ramp up Participants worked interactively in teams to create quickly. ECM and Community Supports require a "journey maps" - flowcharts outlining how they would huge expansion of services not previously available ideally like ECM enrollment and engagement to work to Medi-Cal members. Growing the infrastructure from member, CBO, provider and MCP perspectives. to provide these services will take time. Looking at three populations of focus - pregnant and postpartum people, justice-involved individuals, and A Fear. Some nonprofits, particularly smaller ones, people experiencing homelessness - participants are wary of working with much larger, bureaucratic, shared experiences, identified successes and pain and risk-adverse MCPs. points, and brainstormed ideas for improvement. Another interactive brainstorming activity encouraged Challenges for MCPs: participants to dig deep for ideas on how to address A Lack of experience acting as grantees to nonprofit three questions related to ECM: organizations. MCPs must effectively implement and manage a grant process for ECM providers, A How to onboard CBOs and providers to set them which they have to build from scratch. up for success in ECM enrollment A Unfamiliarity with CBOs. MCPs are used to work- A How to use technology to allow humans to be ing with medical providers but not grassroots humans CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 4 A How ECM fits into the broader Population Health Promising Practice Management (PHM) service delivery model within One plan has already launched an ECM Academy in CalAIM, which aims to offer targeted, whole-person partnership with their regional consortium of health care interventions for MCP members at all levels of centers. It's a 6-month training program for organi- acuity, with ECM being the highest level of care zations that want to become ECM providers. The academy teaches them about the credentialing and Numerous ideas emerged from the activities. contracting processes, and skills needed to provide Participants generally praised the process and health services. At the end of the academy, they are ready plan representatives in particular said hearing provider to provide and bill for services. perspectives was eye opening. Key Challenges and Proposed "The reality is the field wasn't ready. There's so Solutions much money being infused and, while we're The following six solutions emerged from the collab- orative discussions MCPs and providers had regarding grateful for those dollars, it doesn't immediately challenges they commonly face. fix the problems. Non-profits have to have the time and training to be able to increase CHALLENGE #1:Many providers feel overwhelmed by CalAIM, and there is a need to build the capacity to the level that we need." confidence and capacity. -Kelly Bruno-Nelson, executive director of Medi-Cal and CalAIM, CalOptima Health PROPOSED SOLUTION: Launch training academies to support providers with onboarding to CalAIM CHALLENGE #2: CHWs are critical for community and ongoing management​. engagement, but most organizations struggle with recruitment and retention. I​nspired by the lessons learned from one plan's ECM academy, participants envisioned an "integrated sup- PROPOSED SOLUTION: Collaborate across MCPs port services academy" that would help doulas and and providers to train and reward CHWs. CHWs better support ECM's seven core services, Participants reimagined recruitment for these criti- which are universally available to all populations of cal frontline health workers. ​What if MCPs and providers focus. They imagined two separate tracks - one joined forces to guarantee jobs for those who finish for doulas and another for CHWs - that would the CHW certification course? ​And what if this part- offer a tailored curricula focused on key services nership also created three clear tracks to becoming and operational structures. Participants hypothe- a certified CHW? The first track would be for some- sized that such a program could be an opportunity one who has no experience as a CHW, the second for to strengthen community engagement, trust, and someone with lived experience who is well positioned capacity across regions and cultures. ​ to work with patients with complex needs, and the third for someone who has already been working as a CHW in their community but who hasn't yet become certified.​Other participants flagged the importance of providing stipends to cover training costs and raising CHW wages to improve retention. CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 5 CHALLENGE #3:Housing navigation services are that patient to a postpartum provider would serve needed, but there is not enough housing.​ their primary need at that moment, whereas a home- PROPOSED SOLUTION: Define measures of success less provider might not be prepared to address for navigation with the reality of insufficient postpartum issues. ​ housing in mind, and introduce tiered navigation based on need​. "When I manage my teams, I want to make sure Participants envisioned using three separate tiers for they're spending the most amount of time in housing navigation and reimbursement. The first tier front of the patient, actually engaging in really would offer intensive support for community mem- bers who need help getting their paperwork in order valuable care to move the needle forward for to be considered for housing. The second would their (health), not sitting at their computer provide basic support for community members who double documenting." have their paperwork ready but who need a regu- -Kaska, Healthcare in Action lar point person they can check in with and who can match them with housing when it becomes available, CHALLENGE #5: Data exchange is one of the main such as a CHW. Intensive outreach would be given to obstacles faced across implementation partners. community members in the third tier, who have the paperwork ready but are hard to find and connect PROPOSED SOLUTION: Request DHCS provide clear expectations on data standards and with and need to be kept engaged while waiting to be sharing. MCPs can then lead the way to support matched with a housing opportunity. ​ providers and CBOs in adopting technologies and improving data flow​. ECM enrollment needs to increase, CHALLENGE #4: and ECM engagement needs to improve. To accelerate the quality and sharing of data, MCPs, providers and CBOs can brainstorm ideas for data PROPOSED SOLUTION: Reimagine how to identify who is eligible, match with providers, and plan standards and sharing requirements together with for transitions​. DHCS. One particular challenge that was brought up was how to exchange data from the sheriff's office Conference participants drew from experience to to providers outside the criminal justice system. An share various creative ideas for how to achieve this, MCP suggested that managed care plans, which have including not authorizing ECM prior to providing ser- high touchpoints with different providers, could serve vices, or using birth certificates to identify patients in as conduits of this information. In this scenario, the the postpartum population of focus. ​ county jail would fax release dates to an ECM provider working with the jail. The MCP would then automate One attendee pointed out that while there are many those faxes and load them onto an electronic plat- criteria to identify "adult nursing facility residents" form that they could use to translate data to providers as population of focus, very few exist for predicting on the outside. ​ a successful transition into the community. Another participant shared that while their health plan pays different rates for different populations of focus, they do not use a population hierarchy to assign members to services or providers. For instance, if a patient is both postpartum and homeless, assigning CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 6 Double documenting "is an extraordinarily burden- Promising Practice some task for an individual who is taking care of 40, One plan is helping fund a data exchange using maybe more, very, very high acuity patients," Kaska Epic EHR software in collaboration with the county, said. "When I manage my teams, I want to make sure and with input from the health plan, providers, and they're spending the most amount of time in front of CBOs. As part of this effort, the plan is also work- the patient, actually engaging in really valuable care to ing to automate the electronic transmission of jail move the needle forward for their (health), not sitting release records from the county sheriff's office to at their computer double documenting." the health plan. The data exchange is expected to launch in 2024. Next Steps Participants emerged from the conference energized CHALLENGE #6: Staff burnout is one of the main by the prospect of future collaborative discussions barriers to success, while administrative burden around ECM and other CalAIM programs. Many is driving an exodus from the field. expressed support for MCPs, medical providers, and CBOs continuing to work together to address com- PROPOSED SOLUTION: Use technology to allow mon challenges. humans to be humans, and minimize time consuming routine work that can be automated. Kristy Garan-Martinez, senior director of ECM for the Participants suggested collaborating across MCPs, pro- Inland Empire Health Plan, said she had exchanged viders, and CBOs to identify the main challenges that phone numbers with representatives from several can be addressed with digital tools for automation. ​ health plans and providers at the event, and was plan- Several providers noted that they are being forced ning to follow up on the data sharing and training to double document their interactions with patients academy ideas. "I feel like I can phone a friend when in both their organization's internal electronic records I'm in need of sharing thoughts," she said. "And to system and that of their MCP. discuss how to operationalize guidance from the state and how to overcome barriers." Kaska with Healthcare in Action proposed enabling a streamlined system in which information created "I feel like I can phone a friend when I'm in internally would be automatically transmitted to health plans. This could be done through an appli- need of sharing thoughts and to discuss how cation programming interface (API) that allows to operationalize guidance from the state and computer programs to communicate with each other, how to overcome barriers." one participant suggested. Others built on the sug- -Kristy Garan-Martinez, senior director of ECM, gestion, proposing that providers and MCPs develop Inland Empire Health Plan small proofs of concept to capture the benefits and refine the solutions. MCPs could then support broad Eric Schwimmer, program director for CalAIM and adoption across provider networks. ​ ECM at Anthem Blue Cross, said he hoped the con- ference would allow ECM implementers to present a more unified front when talking to state regulators. He sees gaps in the safety net and views siloed health and social service delivery systems as major hurdles to ECM implementation. CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 7 "Success in my program depends upon the environ- About the Author ment that its being developed within," he said. "The Claudia Boyd-Barrett is a longtime journalist based in value of this forum is that we can talk about this stuff Southern California. She writes regularly about health and maybe, as a collective ECM voice, we can talk and social inequities. Her stories have appeared in to DHCS and other stakeholders about that, and it's the Los Angeles Times, the San Francisco Chronicle, more powerful than just me." the San Diego Union Tribune, and California Health Report, among others. As the day closed with participants prioritizing their takeaways, one clear winner stood out: "Everything Boyd-Barrett is a two-time USC Annenberg Center for we do needs to support the member in achieving their Health Journalism fellow and a former Inter American ideal state." Press Association fellow. About the Foundation The California Health Care Foundation (CHCF) is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 8 Endnotes 1. "Medi-Cal Transformation: Our Journey to a Healthier California for All," California Department of Health Care Services (DHCS), accessed November 2023. 2. CalAIM Enhanced Care Management Policy Guide (PDF), DHCS, updated September 2023. 3. CalAIM Enhanced Care Management Policy Guide, DHCS, 9. CalAIM Perspectives: How to Improve Enrollment in Enhanced Care Management www.chcf.org 9