Cassie Call, Brooke Ehrenpreis, Christopher Langston, Jasmine Lacsamana, Jane Ogle, Laura Rath, and Carly Roman also contributed to this post.
California Health Policy Strategies, LLC, (CalHPS) in collaboration with Archstone Foundation, is sponsoring an exciting new statewide learning collaborative to support the integration of CalAIM (California Advancing and Innovating Medi-Cal) and community-based dementia related and other programs that serve individuals at high risk of institutionalization. Community-based organizations, providers, and managed care plans will work together to share lessons and learn from one another. CalAIM is an ambitious and visionary game-changer that has enormous potential to improve care for millions in our state who rely on Medi-Cal or who are dually eligible for both Medi-Cal and Medicare.
CalAIM is a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory. With a population health approach focused on whole person care outside of traditional health care settings, CalAIM creates opportunities to improve care coordination and delivery for Medi-Cal or dually eligible older adults with dementia who are most likely to be at risk for institutionalization.
State Street Medicine Learning Collaborative – A Successful Technical Assistance Approach
Bringing together organizations and stakeholders around a common objective can focus discussion and opportunities for problem-solving. The new statewide CalAIM learning collaborative on dementia is modeled after a similar effort that supports street medicine community-based organizations that provide health care services for individuals experiencing homelessness. CalHPS has helped facilitate the learning collaborative structure that is bringing together street medicine providers, managed care plans, stakeholders, and state Department of Health Care Services (DHCS) to develop contracting strategies with Medi-Cal managed care plans for Enhanced Care Management (ECM), Community Supports (CS), and clinical services provided in the field to unsheltered individuals.
The collaborative has helped focus attention on the challenges in providing health care services to the unsheltered population of focus as well as the value of street medicine providers. DHCS has responded by issuing state guidance on how managed care plans should be contracting with street medicine providers. DHCS has also included requirements for health plans to include street medicine as part of the Housing and Homeless Incentive Program (H-HIP). The collaborative has been focused on getting health plan funding through the incentive program, contracts to provide clinical services, and enhanced care management contracts.
CalAIM Statewide Dementia Learning Collaborative
Using the successful structure of the street medicine collaborative, on October 27, 2023 we launched a new statewide learning collaborative to support the integration of CalAIM and community-based dementia programs. More than 70 attendees joined our kick-off webinar and discussion.
To start us off, Christopher Langston, Archstone Foundation President and CEO shared that improving care for persons living with dementia and their caregivers through CalAIM is important to Archstone Foundation’s mission for three reasons:
- It is a chance to address equity in health by reducing health disparities.
- We have a critical opportunity to make sure these new systems will meet the needs of older adults, in this case persons living with dementia and their caregivers.
- Our partners are in a unique position to offer social services in partnership with health providers to better care for people with complex health needs.
Who Will Ultimately Benefit from the Learning Collaborative?
The collaborative is primarily focused on older adults (65+) with dementia who are eligible for Medi-Cal (with or without Medicare) and CalAIM services. Enhanced Care Management (ECM) is a Medi-Cal benefit that addresses clinical and non-clinical needs of high-need, high-cost individuals through coordination of services and comprehensive care management. Adults living in the community and at risk for long term care institutionalization – a CalAIM population of focus as of January 1, 2023 – is a population likely to include many persons with dementia. In fact, we estimate that there are ~128,000 individuals with dementia who are at risk for institutionalization and are eligible for enhanced care management and community support services.
How did we arrive at that estimate? A little back-of-napkin calculation: There are 1.4 million older adults who are dually eligible for Medi-Cal and Medicare. While we know the estimated prevalence of dementia in California is 12.0%, among dually eligible individuals the prevalence is much higher at 18.1%. Taking 1.4 million times 18%, and then dividing it by two (to reflect that some persons living with dementia who are already living in institutional settings or are stably cared for at home), we get an estimate of 128,000.
Improving care and coordination of services such as nursing facility transitions, home delivered meals, and respite services to persons living with dementia and their caregivers is also an opportunity to provide equitable care. Women and people of color are disproportionately dually eligible, making this a critical opportunity to reduce health disparities.
Based on currently limited anecdotal data, my CalHPS colleague, Brooke Erhenpreis, shared our view that few eligible individuals with dementia or at risk of institutionalization have been enrolled into CalAIM’s ECM. Given the need, this is a ripe opportunity to focus our attention and provide better, more thoughtful coordinated care.
Engagement with Medi-Cal Managed Care Plans (MCPs)
In CalAIM, Medi-Cal managed care plans (MCPs) are central to implementation. The DHCS provides MCPs with the funding and responsibility for CalAIM’s success. The MCPs are also held accountable for achieving results and improved health outcomes for their Medi-Cal enrollees. The kick-off webinar included introductions from Kate Ross, with the California Association of Health Plans, and Rebecca Sullivan with the Local Health Plans of California. As representatives from the two major California health plan associations, Kate and Rebecca acknowledged the need for the new state collaborative and welcomed the opportunity to partner with community-based organizations to provide better care and services to the population of focus of individuals at risk of institutionalization and those with dementia.
Making It Real - Experiences with CalAIM
In the second half of the discussion we heard from leaders across the state who are engaging in this work.
Jennifer Schlesinger, Vice President, Healthcare Services & Professional Training at Alzheimer’s Los Angeles, shared their current thinking about CalAIM. Alzheimer’s Los Angeles is a local community-based organization that has been serving the LA community for over 40 years. They are actively involved in the enhanced care management space and are currently involved in the contracting process in Los Angeles.
Jennifer observed some unique considerations and challenges in caring for persons living with dementia and their caregivers. As a population that tends to be undiagnosed and underdiagnosed, there are tools that community-based organizations need to access to help them identify people who could benefit from services. Individual health plans are differently equipped to handle data monitoring and support for community-based organizations in identifying potential members, making partnerships between community-based organizations and managed care plans critical to foster.
She also stressed the importance of providing quality, person-centered care for persons living with dementia and their caregivers. Given behavioral and neuropsychiatric symptoms often associated with dementia, having a stranger show up can be confusing for the person and their caregiver. Therefore, personalized ways of connecting with families need to be considered and implemented. Community-based organizations need staff support with dedicated resources to provide those personalized connections.
Next, we heard from June Simmons, President and CEO of Partners in Care Foundation, an organization with a strong presence in care coordination especially for older populations. For years, Partners has been interested in moving funds in health care upstream to address social factors that drive healthcare needs. June shared, “I admire the State of California for bringing forward his bold vision forward.”
She discussed that this is a transformative opportunity, but it also comes with disruptive changes, including the need to redesign the system around social determinants of health and the need to create a financially sustainable system. It goes beyond a contract with a health plan, although that’s also necessary. For example, in Los Angeles, there are five different health plans, each with unique and different contract processes, workflows, payment structures, and billing arrangements, making administrative complexity a significant issue deserving of time and attention to make contracting with health plans efficient for community-based organizations.
Another critical issue June raised is enrolling a meaningful number of people to make the funding work. For example, community-based organizations must understand how Federally Qualified Health Centers, physician groups, health plans, and hospitals will identify this population of focus and make referrals. They need to know how the compensation will be structured. These are new business arrangements, so we must consider: How many agencies can and should be equipped to do this work? Then we need to learn and work together so individual agencies don’t need to reinvent the wheel.
Rounding out the group was Lena Haroutunian, Program Director from New Sunrise Adult Day Health Center (Community-Based Adult Services), located in Northridge, California. New Sunrise is a provider of enhanced care management and community supports, and they work with HealthNet, Molina, and Anthem to provide meals, respite, and nursing facility transition diversion.
While there have been many CalAIM webinars, they have not been specifically about this population of focus. People living with dementia and their caregivers are an underserved group that faces health inequities, yet we’re still not providing training or talking about what resources are available. This is a critical time to connect with others who are currently serving this population of focus, and this learning collaborative provides that structure.
What’s Next: How You Can Join Us to Improve Care for Persons with Dementia
We hear a clear consensus that this is a significant opportunity to provide better care for people living with dementia and their caregivers. If you’d like to get involved, we invite you to check out the resources on Archstone Foundation’s website and to join us for an upcoming learning collaborative meeting:
Dementia-Specific Workgroup - Register here
- Friday, November 17, 12:00pm-1:00pm
Community Based Organizations Workgroup – CBOs interested in contracting - Register here
- Friday, November 17, 3:00pm-4:00pm
Statewide Learning Collaborative Meeting #2 - Register here
- Friday, December 1, 12:00pm-1:00pm
We hope you will join us in improving care for persons with dementia and their caregivers and hope our state can guide the way for others in closing health disparities.
