Medi-Cal Enhancements for at-Risk Populations: What Does it Mean for Providers?

Today’s healthcare industry is becoming increasingly focused on care coordination – using advances in technology to share information, analyze risk factors and improve outcomes across multiple settings. We live in a connected world, and individuals need treatment that reflects the complexity of diverse care settings and providers. California understands this need. As usual, the Golden State is leading the way with forward-looking, promising new efforts to increase care access for all – even the most vulnerable populations.

Two integral programs are at the forefront of behavioral health in California: Enhanced Care Management/Community Supports and CARE Court. These are significant advancements to Medi-Cal and are expected to yield improved care outcomes in California through care coordination. But they bring change for providers if we want them to succeed. Let’s take a look at both programs and how they will affect behavioral health organizations.

First, Enhanced Care Management (ECM) is a statewide Medi-Cal benefit which provides case management services to members with complex needs. This means members belonging to one or more high-risk “populations of focus,” including:

·       Individuals and families experiencing homelessness

·       Individuals at risk for avoidable hospitalizations

·       Individuals with serious mental health and/or substance use disorder needs

·       Individuals transitioning from incarceration

·       Adults living in the community who are at risk for long-term institutionalization

·       Adult nursing facility residents transitioning to the community

·      Children and youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CSS condition

·       Children and youth involved in child welfare

·       Birth equity population

Members of these populations are often unable to access the care they need due to structural barriers. This could be unemployment, transportation, substance use disorder or poverty. The problem is that without appropriate access to care, these populations are at higher risk for incarceration, experiencing homelessness or hospitalization. To prevent this, every Medi-Cal member who qualifies for ECM will receive a dedicated Lead Care Manager and the ECM team will ensure they are connected to quality care wherever they go––the doctor, the dentist, with a social worker or at a community center.

Community Supports are a broader part of the ECM initiative that are meant to reach a wider population of Medi-Cal members. In other words, some people may not qualify for ECM but will qualify for Community Supports. These services help high-risk individuals and families live healthier lives in the least restrictive setting possible. We don’t want individuals flooding high-cost care settings like the emergency department or nursing facilities. Community Supports provide treatments that address health-related social needs and keep individuals and families in their communities whenever appropriate. Examples of Community Supports services include:

·       Support for securing and maintaining housing

·       Access to medically tailored meals for short-term recovery

·       School-based intervention

·       Sobering centers

Finally, a separate initiative that’s new to California is Community Assistance, Recovery and Empowerment (CARE) Court. This is a transformational program targeting members with severe mental illness (schizophrenia or related psychosis) who are not currently receiving the voluntary treatment they need. CARE Court allows family members, medical professionals and even roommates to petition so that the individual can receive treatment under Medi-Cal. According to proponents like Governor Gavin Newsom, this will reduce homelessness and mass incarceration in California by bringing mental health care to those who might otherwise fall between the cracks. 

As providers, it’s easy to see how these programs will result in better outcomes for a greater number of Californians. But it’s also clear that organizations will need to make changes to accommodate these new improvements. While we’ve seen programs like this before, implementing ECM/CSS and CARE Court simultaneously can be an opportunity for providers to proactively manage multiple care programs. Organizations will need an overarching view of these different programs as individuals transition between levels of care––or care coordination teams––based on their needs across the healthcare continuum.  Fortunately, there are resources that can help you optimize care and simplify implementation. Proven strategies and technology tools exist, often using a comprehensive care management platform – alongside your EHR. Whether it’s patient records, assigning caseloads, billing or partnering with Lead Care Managers and CARE Court staff, you can ensure that procedures are followed with efficiency and ease.

Above all, providing the right support at the right time is the goal. When a patient is admitted to the emergency department, becomes unhoused, or enters/leaves incarceration, it’s important for you to be part of the treatment process. This will foster even greater collaboration between behavioral health providers and community support systems like schools, food banks and housing agencies.

With this level of care coordination, your organization can partner with the state of California to improve outcomes not just for individuals, but for entire communities. We’re all in this together, and you can make a difference.