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Learnings from the CalAIM Academy for Hospitals and Health Care Systems
As a key leader, resource, and employer in their community, a hospital not only provides lifesaving health care but also influences their community’s direction and improvement efforts in times of stability and in times of disruption. In an emerging trend, hospitals in California are playing a vital role in co-creating community-wide delivery systems to meet complex care needs in a systemic and sustainable way. By working together and keeping patients at the center of their efforts, hospitals lean into their mission and communities have the opportunity to improve health and well-being.
As hospitals shared in a 2025 webinar series, they in turn benefit from this structure through: 1) strengthened community partnerships, 2) increased revenue and business development, 3) decreased costs, and 4) reduced burden on inpatient and emergency department services.
The California Advancing and Innovating Medi-Cal (CalAIM) program is one model that can be leveraged to connect providers across a community in a delivery system that transforms the lives of Medi-Cal members with complex needs and strengthens a community and hospital, even amid Medi-Cal (California Medicaid) reductions. An early study published in a 2025 Community Supports Annual Report showed that CalAIM Community Supports are reducing health care costs and utilization among patients with the highest needs.
Funded by the California Health Care Foundation (CHCF), the CalAIM Academy for Hospitals and Health Systems webinar series with Communities Lifting Communities equipped a broad cadre of hospital and health system leaders to partner across the health care and social services sector and collectively improve the health of Medi-Cal members through the unique opportunities presented by CalAIM initiatives.
Through the Academy, five key practices emerged that contribute to a hospital’s ability to co-create care models that align with its mission, put people at the center, and meet community needs:
- Understand the hospital’s role
- Integrate into mission and strategy
- Assess community needs
- Align with existing systems and infrastructure
- Partner with others
1. Understand the hospital’s role
We really see [CalAIM] as an opportunity to build the local continuum of care. Our mission is really what drives this work. So ‘living God’s love by inspiring health, wholeness and hope,’ we are here to serve our community and therefore take care of the patients that we see every single day and address them from a whole-person perspective. – Yesenia Mock, Administrative Director of ACO and Value-Based Care for Adventist Health, which provides ECM and Community Supports in 15 California counties, CalAIM Academy for Hospitals and Health Systems, Session 3, starting at 20:57
As a mission-driven community institution with significant resources and high-leverage touchpoints across a patient’s journey, every hospital has a key role in community health transformation efforts. In addition, a large percentage of hospital emergency department patients are Medicaid members with complex health needs – who can benefit most from a systematic, holistic approach to care.
When Medicaid access is reduced, newly uninsured patients with complex health needs will still need health care. Community partnerships and outreach can reduce the volume and impact of unreimbursed services by addressing social drivers of health such as homelessness and substance use disorders and by providing post-acute services that can provide a safe place to recover after hospital discharge.
Community services that address a patient’s health and well-being are traditionally provided in silos, with organizations doing great work but in a fragmented way. Many hospitals are leveraging their leadership to bring these services together into a connected system of care, much like has been done with clinical care systems over many years. System integration is becoming a pre- and post-acute care strategy that centers on the patient.
Whether with CalAIM or other programs, a hospital can take many different roles in system integration. In some cases, it is providing holistic services to their patients themselves (vertical integration), and in others, it is setting up a care delivery system with community partners (horizontal integration).
2. Integrate into Mission and Strategy
Prioritizing and building care models that meet community needs require executive buy-in and integration into mission and strategy. Hospitals should think about how whole-person care aligns with their organization’s mission and purpose and make the connection clearly. From there, they can explore how organizational structure and roles can reduce fragmentation and how coordination with community partners can seamlessly close gaps in care.
Internal alignment requires buy-in from multiple key leaders and departments.
- Executives and boards have an opportunity to shape strategy with a member-centered focus, making it a strategic initiative to get patients the resources they need. They can also assert community-wide leadership and partnerships.
- Community and population health teams have relationships with organizations in the community providing services to patients and can shepherd the organizations to become connected in a more systematic way.
- Because clinical providers and case managers are already doing this work, often uncompensated by payers, they can help navigate how to get reimbursed for that existing infrastructure.
- Finally, strategy and business development teams can assess the impact on efficiency, utilization, reimbursement, and costs.
All of these teams should come together as one team to put services together that are in the best interest of the community.
To generate buy-in for transformation work from others, keep these tips in mind:
Once a hospital has made clear how a community-wide care model aligns with their mission and made it a strategic priority, they can explore the funding models that will support it, such as CalAIM, which has provided start-up funding, technical assistance, and ongoing reimbursement for services that serve Medi-Cal members with complex needs.
3. Assess Community Needs
Putting community at the center starts with deeply understanding the community’s needs and assets and shaping strategy from there. Hospitals have a wealth of data at their fingertips that can be utilized for this. Reports on emergency department and inpatient stays by people with complex needs can show trends in demographics and physical, behavioral, and social conditions. The figure below shows typical sub-populations of people with complex needs that can give some insight into the holistic services that these groups may need.
Community health reports can also guide hospital strategy by providing a comprehensive view of their community, emerging sub-populations and needs, key community partnerships, and mission-aligned priorities and strategies. This table describes four of these reports.
4. Align with Existing Systems and Infrastructure in a Vertical Integration Strategy
Learn how Adventist Health organized their internal structures and workflows to maximize their CalAIM efforts. View the CalAIM Academy Session 3 recording from 21:00-59:00.
With a deep understanding of the community and their needs, a hospital can align the needed services with their existing care delivery system and its potential transformation. This is sometimes called “vertical integration.”
Key questions to guide this strategy include:
- What services do we already provide that align with the community’s needs? What services align with reimbursable services via CalAIM?
- What sub-populations of focus stand out in our data, and what support services currently exist for them? Do any of these populations align with CalAIM ECM populations of focus?
- What existing committees, teams, and meetings could fit with intentional transformation of the care delivery system, such as via CalAIM? Or, who might we bring together to form a new team (i.e., leadership, case management, contracting, finance)? What would the organizational structure look like? Who do we need, or what do we need to build in order for this work to be successful?
- What new policies, procedures, workflows, trainings, and data and IT systems would we need to make this work?
- What funding models, such as CalAIM, would support this work?
5. Partner with Others in Horizontal Integration
Learn how Sharp Coronado Hospital and Serene Health set up workflows, processes, and communication practices to make the most of CalAIM services. View the CalAIM Academy Session 4 recording from 28:00-47:00.
To build care models that serve the whole person, hospitals often coordinate with partners outside their organization to fill gaps in their services and to leverage expertise and trust built by others in the community. This partnership strategy is also known as “horizontal integration.”
To get started, hospitals should find out who provides services that match community needs. For example, they should explore who provides CalAIM services in the local area and how to make referrals to them. For effective partnerships, it’s important to:
- Align on shared mission.
- Build a relationship.
- Co-create a seamless way to share data, make referrals, and create connections for patients.
Hospitals can take various roles in partnerships and in the ecosystem, including:
Summary
California hospitals are serving on the leading edge of community transformation by co-investing in a strategic system of care to escape the ineffective, inefficient cycles of working in silos. Key steps in that transformation include understanding their role, integrating community-wide delivery systems into their mission and strategy, assessing community needs, and building associated infrastructure and partnerships. CalAIM is one program that can help hospitals live their mission, transform care systems for patients who are Medi-Cal members, and expand their business and partnerships.
Hospital Successes Through CalAIM
“We saved a member’s life during an outreach attempt. They had fallen out of bed the night before, and it was a Friday. They would’ve lain on the floor all weekend. And the doctor at the ED said she would’ve perished if we hadn’t been doing outreach. …
“A member who quit smoking cigarettes for a surgery. She’s in her 70s and smoked … her whole life, and she quit smoking for surgery. What an accomplishment!
“A disruptive member in the emergency department every other week. And his last visit was in October [seven months ago]. Guess what happened? That was his enrollment month in ECM. He hasn’t been to the ED since.
– Joanna Garneau, Program Manager, Eastern Plumas Health Care, CalAIM Academy for Hospitals and Health Systems, Session 3, starting at 31:49
Author and Contact for More Information: Rebecca Brandes, MPH
HC2 Strategies Director of Community Impact
Rebecca@hc2strategies.com
