Case Study: Building Long-Term Sustainability of CalAIM Services through a Coordination Role
Medicaid transformation in California is bringing together mission-focused people at all levels of state government and community to deploy myriad new and innovative social services and funding to care for members with complex needs. State health department leaders, county health workers, managed care plan (MCP) managers, community-based organization (CBO) staff and health system employees, among others, are building community systems of care that will extend and enhance the lives of millions of Californians.
Many of these organizations have been serving their communities on their own, and now, with CalAIM, or California Advancing and Innovating Medi-Cal initiatives, they are working more closely together through Providing Access and Transforming Health (PATH) Collaborative Planning and Implementation (CPI) groups and other connecting organizations. This collaboration has revealed the demand for dedicated, long-term coordination to make the best use of community resources and to help guide members to the best services for their needs
Need for Coordination
When coordination is done well, two positive results emerge: Eligible members find their way to and through services easily, and the jobs of the frontline workers providing the services become easier and more effective.
The long-term effective utilization of CalAIM’s Enhanced Care Management (ECM) and Community Supports services will depend on this coordination. After the start-up funding ends and the CPIs have wrapped up their last meeting, the system of care must continue. Communities need to build the relationships and knowledge of available services required to serve members and refer them to the best service for their needs.
An emerging coordination best practice is the role of a coordinator or integrator to bring all the services together.*
Job Description
A CalAIM coordinator is someone who understands both the details of how CalAIM services can meet client needs and the scope of the broader, non-CalAIM service delivery system. They can recognize the opportunities for collaboration and integration in the community. They know MCPs’ expectations and how to provide support regarding those expectations (e.g., linking providers to best-practice trainings for trauma-informed care and motivational interviewing and to their local continuum of care (CoC), homeless information management system (HMIS) and other resources).
Nationally, training for the integrator or coordinator role encompasses systems thinking, facilitation skills, project management and leadership in complex care delivery. The ideal coordinator possesses client-facing experience, a human-centered approach to various systems and the ability to find creative solutions to care coordination challenges in real time. Successful candidates for this role often come from diverse backgrounds, including nursing, social work, direct service provision and even faith leadership.
Some larger organizations appoint their own CalAIM coordinators to focus on relationship-building and problem-solving within the organization. In smaller communities, a countywide coordinator can effectively connect the population and provider community. However, in more densely populated areas, coordinators often specialize in serving specific populations, such as children and youth or the unhoused.
CalAIM Coordinator
In Kings and Tulare counties in the rural central San Joaquin Valley, Iris Gitcho serves as the CalAIM coordinator with the Kings/Tulare Homeless Alliance, the counties’ designated Continuum of Care Program. This role arose from partnership discussions among the Homeless Alliance and the counties’ Medi-Cal managed care plans at the time, Anthem Blue Cross and Health Net/CalViva. The groups, which enjoy a strong partnership history, co-developed the concept and job description and helped to implement it, a key success factor.
- Enhanced Care Management (ECM), which addresses the clinical and non-clinical needs of high-need individuals by coordinating services and providing comprehensive care management
- Housing Navigation, or assistance to find, apply for and secure housing
- Housing Deposits, which help members with the one-time services, such as security or utility deposits, that they need to establish a safe household
- Housing Tenancy and Sustaining, support to maintain safe and stable tenancy once housing is secured, such as working with landlords to address issues, helping with the annual housing recertification process, and connecting the member to community resources to prevent eviction
- Day Habilitation Programs, or mentoring to help the member gain the self-help, social and adaptive skills needed to live successfully in the community, such as cooking, cleaning and managing personal finances
Figure 1:
CalAIM Coordinator Function
- Recuperative Care, or Medical Respite, short-term residential care that provides healing support for members who are being discharged from the hospital and lack stable housing
- Short-Term Post-Hospitalization, which is temporary housing for those leaving inpatient care settings, including SUD treatment, mental health, correctional facilities, nursing facilities or recuperative care
- Medically Tailored Meals, or deliveries of nutritious groceries or prepared meals along with vouchers for healthy food and/or nutrition education
- Asthma Remediation, or home modifications to avoid serious asthma episodes. Modifications can include filtered vacuums, dehumidifiers, air filters and ventilation improvements
To help members access these services, Iris works to connect CalAIM and community providers to each other and to Medi-Cal members.
“I serve the people who serve the people,” Iris says. “I have taken our homeless response system and the intersection between our homeless response system and CalAIM and made that my client. I work toward helping that intersection reach its potential.”
Iris brings lived experience to her role along with a rich background in mental health, street outreach and housing navigation, including in downtown Los Angeles. She is deeply committed to getting services to those who need them as quickly and efficiently as possible.
“I have a history of working with people experiencing homelessness on the street where they are,” Iris says. “In that role, I learned what’s important to them. Their stories serve as the lens through which I view this job.”
Functions of the Role
Iris is dedicated to serving the Tulare and Kings community. “We have a lot of wonderful providers, dozens of providers, all working hard to serve the same folks. But we weren’t all working together to serve those folks,” she says. “As CalAIM coordinator, the primary goal that I keep in my mind daily is to help all of us see each other as one unit, working toward the same goal, which is to end homelessness in our area.”
As illustrated in Figure 1, Iris has deployed seven tactics to reach this goal in a region that recorded 1,470 people experiencing homelessness in its Point in Time Count in 2023:
In-Person Meetings: Iris holds these meetings with providers at their service locations to help her better understand their culture, staff, facilities and services. The meetings also help her see where and how each provider connects to the system of care.
Community Education: Connections with junior colleges, healthcare providers and nonprofit organizations that serve clients with Medi-Cal are critical to raising awareness and increasing utilization of ECM and Community Supports services. Iris presents information on local CalAIM services and referral processes to these partnering organizations to help build community-based referrals.
Central Point for Referrals: Iris often serves as the person whom people call first when a client or member experiencing homelessness or at risk of homelessness needs ECM or Community Supports. Because she knows the providers and their capacity well through in-person meetings and case conferencing, she can quickly triage the need and direct the caller to the most appropriate place for a positive outcome.
Asset Mapping: This community-wide exercise helps all providers better see and understand their resources and gaps. Building on an asset map developed in January 2023, Iris worked with Tulare CPI facilitators and members before an in-person meeting in May 2024 to update the resource list for the Tulare County System of Care for Homeless Populations, as seen in Figure 2. The group identified nine new services since the 2023 exercise, and Iris keeps the asset map updated with information she gathers through in-person meetings, case conferencing and HMIS.
HMIS Training and Data: Connecting providers to a centralized database helps them see what services clients have received and are receiving and connect with each other to fill in the gaps.
Iris and another Kings/Tulare Homeless Alliance team member train CalAIM and non-CalAIM providers in the system and encourage providers to join. Iris also regularly reviews and audits HMIS information to help support providers in handoffs and ensure that referrals result in services and care.
Figure 2:
Homeless System of Care Services in Tulare County; shows the number of providers in each service area.
CalAIM Enrollment in Kings & Tulare Counties’ HMIS Since Dedicated Case Finding Began. “Enrollment” means a client has been referred for ECM or a Community Support service. One enrollment is one service.
Case Conferencing: Iris co-leads this monthly meeting with 15 to 20 CalAIM and non-CalAIM providers, which provides them with an opportunity to bring up member cases and work with other providers to find services and solutions for the member right then and there. “With written consent, we bring providers together to talk about their individual needs in their entire life – from medical to mental health to housing and meals – who is serving them, what other services could help them, and who will do that service,” Iris says.
Case Finding: Iris uses this tool to connect community members in the counties’ HMIS to CalAIM services. A triage assessment that is performed for each person in HMIS provides key information that Iris can search to identify members who may be eligible for CalAIM. “For example, clients with 20+ ED visits were referred to a medically based ECM program,” she explains.
After Iris began dedicated case finding in October 2023, the number of enrollments, which refers to each ECM or Community Support referral, increased by 97% in Kings and Tulare counties (Figure 3), from 220 on October 1, 2023, to 433 on June 1, 2024. While other efforts also contributed to the increase, the upward climb began with the start of Iris’s role and case finding.
Results and Learnings from the Coordinator Role
The coordinator role is working.
As Iris brings CalAIM and non-CalAIM providers together through meetings, case conferencing, education, asset mapping and other venues, they see how their programs fit into the bigger homeless response and healthcare systems and how CalAIM can benefit their clients. “The interactions demonstrate that CalAIM is integrated into the Tulare County system of care. There’s one system of care for Medi-Cal members, not one county system and a separate CalAIM system,” she says.
The community partnerships that are forming through Iris’ work extend to data collection. The Kings/Tulare Homeless Alliance, Kings United Way and local Medi-Cal MCPs all work together to coordinate the collection and dissemination of meaningful data.
Case conferencing, which Iris co-leads, generates quick referrals to clients in need. “Referrals are started right there in the room, and we all learn about the client as a whole person.”
The conferences also help providers find members they’re looking for, which can be difficult with the transitory lives of people experiencing homelessness. An ECM outreach coordinator, for example, couldn’t find someone on her Member Information File, a list that MCPs provide to ECM providers with a requirement that they try to connect with members several times in several ways. Most providers in the meeting thought he had left the area, but one knew where he was. That information enabled the outreach coordinator to connect the member to needed services.
Besides locating missing members, Iris also finds eligible Medi-Cal members through case finding. “This process is a labor of love because it requires me to review each file I find to match them to the right service,” she says.
The CalAIM coordinator role, community collaboration and case finding are indicating an increase in enrollment. Seven months after Iris started, HMIS showed 433 CalAIM enrollments, an increase of 213 since October 1, 2023 (Figure 3).
Additional improvements include increases in the number of providers engaged in the Tulare County homelessness system of care from January 2023 to May 2024 (Figure 2) and a 16% increase in ECM utilization from Q3 2023 to Q4 2023.
Funding the Role
Funding for the Kings/Tulare CalAIM coordinator role was braided, using:
- Medi-Cal MCPs’ Incentive Payment Program (IPP) and Housing and Homelessness Incentive Program (HHIP), which were made available to support CalAIM implementation
- State Housing and Community Development Department’s Homeless Housing, Assistance and Prevention (HHAP) Grant Program
- Kings/Tulare Homeless Alliance support
HHIP funding has also been utilized for this role in other regions of California. Providing Access and Transforming Health (PATH) Capacity and Infrastructure Transition, Expansion and Development (CITED) funding is another potential CalAIM source of funding.
In other states, this role has been funded through community benefit, local foundations, hospital 340B dollars, MCPs, and city or county services.
There is national interest in exploring more funding sources to support the role as it has demonstrated value in developing and maintaining effective community coordination to serve those with complex needs.
Other Coordination Options
The CalAIM coordinator role offers a strong return on investment for various organizations and collaboratives. The Kings/Tulare role was built inside the counties’ joint continuum of care for homelessness services, a natural fit for resource-intensive needs. Other potential host or lead organizations might include:
Existing Case Conferencing Tables: When community organizations are gathering to coordinate care through a case conference, they have an opportunity to build on that momentum through identifying a coordination role or duties. Options include initiating process improvements to remove barriers identified for clients in the community. Rotating the leadership role among participating organizations can accelerate implementation and distribute the workload.
Hospitals and Health Systems: Coordination benefits hospitals and health systems by building referral channels to and from their services and by reducing readmissions and lengths of stay. A coordinator will be familiar with the resources available for patients who have been discharged.
Community Foundations: Because community foundations facilitate the collaboration of CBOs to identify, prioritize and fund needs, they may be interested in assisting with identifying a suitable agency or individual for the role and potentially providing funding for it.
Managed Care Plans: A coordination function can help build membership and direct members to intervention services that will improve quality and reduce overall per-member spending.
Next Steps
As CalAIM transitions from implementation to ongoing operations aimed at supporting member success, it is essential to examine the broader policy and structural implications of a coordinator role. Counties and communities require strong, enduring connections among various service providers to effectively utilize community resources. The coordinator role has proven successful in establishing and maintaining such collaboration.
To support ECM and Community Supports growth through coordination, CPI facilitator HC2 Strategies is exploring the creation of a CalAIM coordinator cohort to share resources, learnings and best practices. Details are available by sending an email to TulareCalAIM-CPI@hc2strategies.com.
