Roughly 28 percent of the nation’s homeless population lives in California, with approximately 161,000 residents experiencing homelessness as of 2020 — a crisis which has only worsened due to the COVID-19 pandemic. The state is seeking creative solutions to improve services for this priority population through California Advancing and Innovating Medi-Cal (CalAIM), the state’s new Medicaid waiver program and transformation initiative. Eligible individuals will have access to new Enhanced Care Management (ECM) services and optional Community Supports for Social Drivers of Health benefits. Examples of these services include meeting with a care manager at a shelter, on the street, or in a clinic to identify and address unmet needs and access housing services and medically supportive food. California’s Department of Health Care Services (DHCS) designed ECM, Community Supports, and other components of this transformational effort based on its Whole Person Care pilots, Health Homes program, and Coordinated Care Initiative, as well as from the input of a robust stakeholder engagement initiative.

The Center for Health Care Strategies (CHCS) recently spoke with Jacey Cooper, California’s Medicaid director, to explore how CalAIM seeks to improve care for Californians experiencing homelessness and what other states can learn from this work. This blog post is a product of CHCS’ California Health Care and Homelessness Learning Community, a project supported by the California Health Care Foundation that brought together California-based health care providers, payers, and other organizations to share best practices related to health care for people experiencing homelessness.

Q. How will CalAIM bring together a broad range of stakeholders — the state, counties, managed care plans (MCPs), community-based organizations (CBOs), and providers — to improve the health of Medi-Cal members experiencing homelessness?

A. When the Affordable Care Act (ACA) passed and California expanded coverage for adults, so many individuals who were experiencing homelessness became eligible for Medicaid. While the ACA was very focused on coverage, I don’t think that we ever stopped and stepped back to think about how our delivery system was going to meet the unique needs of this population. What we had was a patchwork of groups working with people experiencing homelessness, including counties that had a clear role in identifying individuals experiencing homelessness and connecting them to housing and MCPs that are responsible for providing reimbursement for services. We didn’t necessarily change the model to caring for people where they are, but that’s the goal of CalAIM — to break down the walls of health care. Waiting for someone who’s experiencing homelessness to show up at a clinic for a three o’clock appointment is not necessarily an ideal approach for them. We had to ask ourselves, “how are we going to change our systems?” 

We needed to step back and acknowledge that there are a lot of players in this space who have all had different roles. Then, weave them together in a comprehensive way.

We needed to step back and acknowledge that there are a lot of players in this space who have all had different roles. Then, weave them together in a comprehensive way. For example, we contract with MCPs to provide medical services. MCPs aren’t out there doing surgery, they’re contracting with a surgeon who does that. Rather than expecting the MCPs to become experts in housing and homelessness, we need them to contract with organizations that do this today. So how do we bring CBOs to the table and draw down some federal funds to bring the two together where they intersect with health? MCPs should be making sure that they have partnerships with counties, CBOs, and others. That takes both knowing that everyone has the best intentions and working together to build these new connections. 

Q. Under CalAIM, DHCS is making a significant investment in health data sharing and supporting infrastructure development through recently approved Providing Access and Transforming Health (PATH) funding. How will this improve health data sharing and ultimately care provided to people experiencing homelessness?

A. We know that we don’t have the best information about Californians experiencing homelessness. We only identify homelessness when someone indicates it on their Medi-Cal application or if it is flagged by a case manager. What we’re trying to do is to create a better way for MCPs to connect to the local Continuum of Care and bolster their understanding of who is experiencing homelessness, because it will drive appropriate referrals to ECM. Oftentimes though, CBOs that know the homeless population — who they are and where they are — don’t have the infrastructure to do reporting and information sharing. So, we created PATH funding to support technology-driven efforts to enhance data sharing, allowing us to know who’s experiencing homelessness, when someone gets housed, and what supports are needed even after individuals have been housed. It’s important for us to put money on the table as we are creating massive changes to make this transformation achievable.

Q. What are you most excited about in the CalAIM Incentive Payment Program that you feel will have the greatest impact on care for people experiencing homelessness? 

A. The Incentive Payment Program is unique because MCPs have to submit a Gap Filling Plan for their first payment. It outlines the needs and gaps in MCP and their providers’ ability to meet and build capacity to fulfill the goals of CalAIM. Essentially, this is a roadmap of where they need to be in a few years. It encourages plans to think long term and thoughtfully design their efforts up front, such as how they will address equity issues. Providing care with a health and social lens is intrinsic to the design of ECM and Community Supports, and so we incorporated measures into the incentive program to support that. For example, we want to see a decrease in the number of Black people experiencing homelessness, because we know that Black people are disproportionally impacted more than other populations. So collecting race and ethnicity data for our members is included in the incentives.

Q. Imagine a newspaper headline five years from now if the CalAIM program is successful in supporting the health and social needs of people experiencing homelessness. What would it say? 

CalAIM improves the health of the most marginalized by breaking down the walls of health care and meeting people where they are.

A. “CalAIM improves the health of the most marginalized by breaking down the walls of health care and meeting people where they are.” That’s what we’re trying to do with CalAIM across all populations. Specifically, for people experiencing homelessness, this is done by connecting people to housing and not just thinking about an emergency room visit. We hope CalAIM improves their health outcomes too. But the difference between weaving health and social services together versus focusing on improving their hemoglobin A1c level is that we are investing in the infrastructure needed to change the trajectory of people’s lives.

Q. Do you have any advice to share with other state Medicaid programs looking to move in this direction? 

A. Building relationships across multiple stakeholders is essential. We spent extensive time on behind-the-scenes and public stakeholder engagement, from making sure all the right people were at the table to inform us, to doing national scans, and having one-on-one conversations. Doing so really helped us build our vision for CalAIM.  It takes being vulnerable — knowing that we aren’t housing and homelessness experts — and letting others with more knowledge than us help shape the program and identify what else we have yet to do.

Be patient for the delivery system to change. We had county pilots across the state during Whole Person Care all doing implementation differently, which was important for our learning. Now we are expanding from those individual microcosms to statewide — with new players, partners, and complications — and standardizing it. Standardization means that in some places we leveled the bar, or raised the bar, and everyone is going to need time to build networks, connections, and delivery systems, and for these things to take hold. Everyone involved needs to remember that this is a journey and will take some time to happen.

We knew it would be difficult to stand up all the initiatives in CalAIM at once. This takes longer, and, to some, isn’t as satisfying as going live all at once.

Do what makes sense for your state. Do the due diligence and learn from other states, but ultimately put what you have learned into context for how things work in your state. We are a big state and had plans and providers in varying states of readiness. We decided to phase-in the implementation across the state for them as well as for us. We knew it would be difficult to stand up all the initiatives in CalAIM at once. This takes longer, and, to some, isn’t as satisfying as going live all at once. Be comfortable in that space as the program ramps up and clearly set expectations the best you can while also acknowledging that tweaks are going to be made along the way.

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