CalAIM at HPSM

To support some of California’s most vulnerable populations, the Department of Health Care Services (DHCS) has rolled out a multi-year initiative called CalAIM — or California Advancing and Innovating Medi-Cal.

Learn more about CalAIM

The goal of CalAIM is to improve health outcomes for Medi-Cal members through changes in delivery systems, programs, payment processes and an expansion of services. In 2022 HPSM began contracting with providers in two new categories: Enhanced Care Management and Community Supports.

Enhanced Care Management (ECM)

ECM is a Medi-Cal only benefit offering comprehensive care management service for our highest needs members (IMPORTANT: Please review eligibility details section below). The services help members address their complex care needs through support that is person-centered and community based.  Only members in specific populations of focus are eligible for this service.  Some exceptions may apply based on eligibility.  See below for eligibility details.

The ECM provider appoints a lead care manager who will work to coordinate a care plan that addresses medical and social needs. The lead care manager coordinates care with the members’ current providers and can support in coordinating their HPSM benefits and other available resources aimed at improving health outcomes.  These services are voluntary.

Members who were enrolled in the Multipurpose Senior Services Program (MSSP) or Whole Person Care  (WPC), which included the Community Care Settings Pilot (CCSP) and Bridges to Wellness (BWT), before January 1, 2022 were automatically enrolled in ECM. 

All other newly identified members must be Medi-Cal members. CareAdvantage members do not qualify for ECM.

Medi-Cal members must fall into one of the following populations of focus to be eligible for services:

  • Adults (21 or older) who are:
    • Experiencing homelessness AND
    • Have at least one complex physical, behavioral, or developmental need with inability to self-manage for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high-cost services 
  • Families or unaccompanied children/youth who:
    • Are experiencing homelessness or housing insecurity OR
    • Are sharing housing with other persons (i.e. couch surfing) due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, camping grounds or shelter.
  • Adults (21 or older) with serious mental health and/or substance use disorders (SUD) with:
    • Serious mental health and/or SUD needs who meet the eligibility criteria for participation in, or are obtaining services through one or more of Specialty Mental Health Services (SMHS) and/or Drug Medi-Cal Organization Delivery System (DMC-ODS) AND
    • At least one complex social risk factor influencing health AND
    • Meet one or more of the following criteria:
      • Pregnant or postpartum OR two emergency department visits or hospital stays for SUD in the last 12 months OR high risk for overdose, suicide or institutionalization OR using crisis and urgent services as primary source of care.
  • Children and youth with serious mental health and/or SUD needs who meet the eligibility criteria for participation in, or are obtaining services through one or more of Specialty Mental Health Services (SMHS) and/or Drug Medi-Cal Organization Delivery System (DMC-ODS).
  • Adults (21 or older) living in the community at risk for long term care (LTC) institutionalization:
    • Presence of qualifying factors for long term care currently or imminent without wrap around care OR who require lower-acuity skilled nursing AND
    • Actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with ADL, access to food, access to stable housing, living alone) AND
    • Able to reside continuously in the community with wraparound supports. 
  • Adults (21 or older) at risk for avoidable hospital or ED utilization (formerly high utilizers) with:
    • Five or more emergency department visits within a 6-month period that could have been avoided AND/OR
    • Three or more unplanned hospital or short-term skilled nursing stays in the last 6months.
  • Children and youth at risk for avoidable hospital or ED utilization with:
    • Three or more ED visits in a 12-month period that could have been avoided AND/OR
    • Two or more unplanned hospital and/or short-term skilled nursing stays in a 12-month period
  • Adults (21 or older) nursing facility residents transitioning to the community who are interested in moving out of the institution; are likely candidates to do so successfully, and are able to reside continuously in the community.
    • An example of an eligible member is one who has:
      • Been a SNF resident at least 60 days.
      • Has cognitive and decision-making capacity or has legal decisionmaker.
      • Has or is able to secure caregiver support or eligible for IHSS hours. Has Activities of Daily Living (ADL) and/or Instrumental Activities of Daily Living (IADL) needs that can be managed in the community with In Home Support Services (IHSS) or caregiver support and improved functional status while in skilled nursing facility.
  • Children and youth enrolled in CCS Whole Child Model with additional needs beyond the CCS condition:
    • Enrolled in CCS WCM AND
    • Are experiencing at least one complex social factor influencing their health
  • Children and youth involved in child welfare who meet one or more of the following conditions:
    • Are under age 21 and are currently receiving foster care in California or previously received foster care in California or another state within the last 12 months
    • Have aged out of foster care up to age 26 if they were in foster care on their 18th birthday or later in California or another state
    • Are under age 18 and eligible for or in  California’s Adoption Assistance Program
    • Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months
  • Birth Equity (Adults and Youth):
    • Adults and Youth who are pregnant OR postpartum (through a 12 month period), AND
    • Are subject to racial or ethnic disparities.
  • Pregnant and postpartum individuals can receive ECM if they qualify under any of the ECM Populations of Focus.

  • Adults and Youth transitioning from incarceration.
    • Adults who:
    • Are transitioning Members eligible for ECM services may also be good candidates for a 1915(c) waiver program; however they cannot be enrolled in ECM and a 1915(c) waiver program at the same time.

     

    For detailed information and eligibility criteria for HPSM’s populations of focus please see DHCS links APL 21-012APL attachment and DHCS ECM Policy Guide.

Community Supports

Community Supports are optional services or settings that are offered to eligible Medi-Cal and CareAdvantage members in place of services or settings covered under Medi-Cal. Community Supports are not a benefit but are medically appropriate and cost-effective alternative services. The goal of these services is to improve the health outcomes and quality of life of Medi-Cal and CareAdvantage recipients by addressing Social Determinants of Health (SDOH).

Medi-Cal and CareAdvantage members that qualify may be authorized to receive Community Support services. Members may already be authorized to a Community Supports provider and may have received a letter notifying them of their qualification for these services. All HPSM members continue to have access to HPSM’s care coordination support care management team.

Members who are eligible for the Enhanced Care Management benefit will be eligible for Community Supports.

A member may be eligible for Community Supports if they meet the following basic qualifications:

  • Active HPSM Medi-Cal or Care Advantage member.
  • Engaged with a Care Manager.
  • Willing to receive community supports.

For detailed information and service-specific eligibility criteria, please see DHCS' Community Supports Policy Guide.

HPSM offers nine Community Support service options to qualified members through our contracted Community Support providers:

  1. Housing Transition Navigation Services*: providing support to include but not limited to advocacy, housing search and coordination of resources based on the member’s individualized needs.
  2. Housing Deposits: identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household (except room and board) based on the member’s individualized needs.
  3. Housing Tenancy and Sustaining Services*: provides tenancy and sustaining services to include but not limited to advocacy, coordination, linkage to resources, life-skills coaching, and health and safety visits with a goal of maintaining stable tenancy once housing is secured based on the member’s individualized needs.
  4. Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for Elderly (RCFEs) and Adult Residential Facilities (ARFs): provides coordination of services to facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for Members with an imminent need for nursing facility level of care (LOC). Members have the choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility when they meet eligibility requirements.
  5. Community Transition Services/Nursing Facility Transition to a Home: provides coordination of services to qualified members which includes but not limited to covering nonrecurring home set-up expenses for eligible members who are able to transition from a licensed facility into the community and prevent further institutionalization based on member’s individual needs.
  6. Environmental Accessibility Adaptations (Home Modifications): provides physical adaptations to a member’s home that are necessary to increase independence or ensure the health, welfare, and safety of a member in their home, without which the member would require institutionalization.
  7. Medically Supportive Food/Meals/Medically Tailored Meals: provides medically tailored home-delivered meals for members with chronic conditions to help achieve their nutrition goals at critical times and help them regain and maintain their health.
  8. Respite Services: provides non-medical, short-term services to members due to the absence of or need for relief for those persons normally providing care to individuals to preempt caregiver burnout.
  9. Personal Care and Homemaker Services: provides assistance to members who could not otherwise remain in their homes with activities of daily living such as bathing, dressing, toileting, ambulation, feeding, meal preparation, grocery shopping, and money management; including services provided through in-home supportive services (IHSS).

Authorization for Services

Enhanced Care Management and Community Supports services require prior authorization.  Providers or care managers, who intend to refer a patient for Enhanced Care Management or Community Supports services, should review capacity and eligibility criteria before submitting any prior authorization forms. A provider list and authorization tips are available in the link below.

Download the ECM and CS Provider List and Authorization Tips

Request Enhanced Care Management services

  1. Review Provider List and Authorization Tips
  2. Complete the HPSM Prior Authorization Request Form.  
  3. Fax the completed form to: 650-829-2079

*Initial ECM authorization periods must be for 12 months. Reauthorization periods thereafter must be for 6 months.*

Request Community Supports

  1. Complete the HPSM Prior Authorization Request Form
  2. Complete the Community Supports Request Information Form
  3. Fax the completed forms to: 650-829-2079

If you are not able to assist a member with requesting prior authorization for these services, and they are interested, please direct members to contact HPSM Care Coordination/Integrated Care Management. The team can assess member’s needs, support with resources, and assist with completing a prior authorization form to request services.

Links to Other CalAIM Resources