Improving outcomes for people experiencing homelessness remains one of the most pressing challenges in California’s health care landscape. Integral to this effort is the collaboration between managed care plans (MCPs) and Coordinated Entry Systems (CES), which often struggle to share data and coordinate efforts effectively. The launch of California Advancing and Innovating Medi-Cal (CalAIM) in January 2022 aims to address these issues by fostering better collaboration to achieve a more coordinated, person-centered, and equitable health system for all Californians, including people experiencing homelessness.

In response to CalAIM’s directives, MCPs, local Continuums of Care (CoCs), and community partners are engaging in cross-sector partnerships to leverage new services and better meet the needs of people experiencing homelessness. While this is a complex and demanding endeavor, a cross-sector team serving two counties in California’s Central Valley exemplifies best practices in effective collaboration. The team, comprised of the Kings Tulare Homeless Alliance (KTHA) — the CoC serving Kings and Tulare Counties — and Anthem Blue Cross, Health Net, and CalViva Health — the MCPs serving Kings and Tulare Counties — partnered and participated in Partnerships for Action: California Health Care & Homelessness Learning Collaborative. This two-year initiative, led by the Center for Health Care Strategies with support from the California Health Care Foundation, showcases how strategic partnerships can drive meaningful improvements in care and support for people experiencing homelessness.

This profile explores lessons from the Kings and Tulare counties cross-sector team’s participation in the initiative, focusing on expanding capacity to better serve individuals experiencing homelessness and innovating within existing systems to support more effective care coordination across organizations.

Takeaways for Health Care and Homeless Service Providers: Four Key Strategies for Improvement

During the initiative, the team worked together to develop and implement innovative strategies aimed at improving care for individuals experiencing homelessness. Below are four strategies worthy of replication by other organizations, as well as early outcomes of this ongoing work in Kings and Tulare Counties.

1. Lay the Foundation for an Impactful Partnership: Collaborative Asset Mapping and Gap Analysis

During the early stages of the initiative, the team recognized the need to conduct a comprehensive gap analysis to identify how to better serve individuals experiencing homelessness. The team worked with National Health and Housing Advisors and HC2 Strategies to develop a local asset map, catalogue available homeless services in these counties, and identify the gaps that needed to be addressed. This analysis was essential in understanding the effectiveness of existing services and pinpointing areas that required additional resources and attention.

These early efforts provided the first opportunity for collaboration among the local CoC (which coordinates housing and services for individuals experiencing homelessness), MCPs, county leaders, and health care and homeless service providers, fostering a deeper understanding of each other’s work. This foundational work was critical. The early planning enhanced the team’s ability to prioritize what their counties needed most and identify what existing services they could improve and build upon, ensuring a more effective and coordinated approach. By strengthening cross-sector partnerships, the team was able to lay the groundwork for their future successes, as outlined below.

2. Identify Opportunities for Capacity Building: Create Positions by Leveraging New Funding Sources

A common barrier homeless service providers face when exploring improvements to care for people experiencing homelessness is lack of funding. As part of CalAIM, DHCS established the Housing and Homelessness Incentive Program (HHIP) and the Incentive Payment Program (IPP) that allow Medi-Cal (Medicaid) MCPs to earn incentive payments for investing in efforts to address homelessness. To access this funding, the MCPs, as required by the state, must outline how these funds would support and improve care for people experiencing homelessness.  By leveraging these HHIP and IPP funds, the managed care plans were able to support the addition of these critical positions “on the ground” at the CoC, building needed capacity around coordination and health equity.   

Working together, Anthem Blue Cross, Health Net, and CalViva Health funded three new positions at the CoC.  These included:

• A Street Medicine Housing Navigator will partner with Kaweah Health, a local health system, on their street medicine program. The navigator provided connections to the homeless response system for people served through the program.  The CoC contributed their sprinter van to these partnership activities to provide privacy and space for consultation between the navigator and patients. 
• A Racial Equity Coordinator to build local capacity to address policy and practice challenges using a racial equity lens. The coordinator helped to develop a racial equity improvement plan to identify key priorities and system improvements.  Examples included: creating a racial equity dashboard to analyze where disparities might exist between race, age and gender in people served by the CoC; a committee consisting of people with lived experience to advise the CoC; and a youth advisory board to focus on the unique needs of youth experiencing homelessness. The overall partnership between MCPs and the CoC as well as additional highlights on their racial equity activities are featured on this webinar.
•  A CalAIM Coordinator to support integrating CalAIM services into the existing homeless response and CES. The coordinator builds relationships across cross-sector service providers, including health care, housing, behavioral health, and county services, to enhance collaboration across organizations and streamline service delivery for individuals experiencing homelessness.  Ultimately, this role served as a breakthrough for the team by expanding capacity and clarifying roles for each of the cross-sector partner organizations.

The MCPs have begun planning for how they will support these positions directly when the state incentive funding ends.  

3.  Integrate Services and Systems: Build Relationships, Tools and Processes

The new CalAIM Coordinator position, described above, has been pivotal in supporting the integration of CalAIM services into the existing homeless response and coordinated entry system (CES). The coordinator builds relationships across cross-sector service providers, including health care, housing, behavioral health, and county services, to enhance collaboration across organizations and streamline service delivery for individuals experiencing homelessness. The team developed a CES map to explain the system to service providers, helping them to better understand and, thereby, more effectively refer to and receive referrals from the CES. This tool has resulted in new and optimized partnerships, such as connecting new medical respite and street medicine providers to the CES and MCPs.  The resulting integration has made services more effective, boosting the overall efficiency and impact of the health care system and homeless response system in these counties.

The team has further integrated the health care and homeless response systems by adding CalAIM providers to existing monthly case management round table meetings for the homeless response system. This allows for CalAIM and non-CalAIM service providers to collaborate and learn from each other through training and case conferencing to ensure clients are receive the care and services they need.

4. Improve Care and Outcomes: Initiate a Local Data Matching Project

Through collaborative efforts with MCPs and local service providers, KTHA —as the local CoC — initiated a member data-matching project with the city of Tulare. The initiative, supported in part by local Encampment Resolution Fund resources, systematically identified individuals in the HMIS data who met the eligibility criteria for CalAIM’s enhanced care management (ECM) services and matched them to MCP member rosters, resulting in increased connections between eligible people and services.

Since the project began, many people have been successfully connected to stable housing solutions. Individuals have also been identified, enrolled in and accessed vital health care services, including CalAIM’s ECM services. Through these efforts, KTHA has demonstrated the potential for impactful change in addressing homelessness within their community and leveraging MCP and city resources to help do so.

Next Steps

The cross-sector team has made significant progress during the last two years as participants in the Partnerships for Action initiative. They have identified opportunities to further refine their partnership and processes to grow their impact.  The core team plans to continue to meet regularly to deepen the cross-sector relationships formed during this project. These partnerships, built on a foundation of shared understanding and collaborative problem-solving, have already demonstrated impacts by improving service delivery and connecting individuals to vital housing and health care resources. The team is committed to enhancing their progress over the past two years and will continue to seek opportunities to improve outcomes for residents in Kings and Tulare counties. Anthem and Kings United Way — the HMIS Lead Agency for Kings and Tulare counties — recently executed a bi-directional HMIS data-sharing agreement, the first of its kind in California with any CoC. The work completed in the Partnerships for Action Learning Collaborative over the past two years laid the groundwork for this agreement to come to fruition.

MCPs in California have been able to enhance their service delivery to individuals experiencing homelessness through cross-system collaboration and by leveraging CalAIM services and resources.  In other states, MCPs interested in replicating these partnerships could consider strategies such as supporting on-the-ground positions within the homeless response system, sharing data across systems to better identify member needs, and working more directly with their homeless service providers, including the CoC.

CoCs and other homeless service providers can leverage their position in the community to marshal city, county, and MCP resources, share helpful information from HMIS, identify needs through asset mapping, and bring together health and homeless service providers to better meet the needs of people experiencing homelessness in their community.