About CalAIM

Community partnerships to create more equitable, coordinated, and person-centered care.

CalAIM Overview

The California Advancing & Innovating Medi-Cal (CalAIM) is a broad Medi-Cal transformation effort to create more equitable, coordinated, and person-centered care. Enhanced Care Management (ECM) and Community Supports (CS) are keystone initiatives engaging Medi-Cal enrollees who are experiencing or at risk of homelessness in coordinated community-based care management and access to housing support services. 

 

Through the Housing & Homelessness Incentive Program (HHIP), Sacramento Steps Forward (SSF) is supporting the Sacramento Continuum of Care, City of Sacramento, Sacramento County, and Medi-Cal Managed Care Plans with integrating CalAIM ECM and CS services into the local homeless response system in alignment with our community’s adopted Local Homeless Action Plan.

 

Note: Sacramento Steps Forward (SSF) is not a direct service provider.

 

For more information related to SSF and CalAIM’s partnership, please contact calaim@sacstepsforward.org.

Enhanced Care Management

Enhanced Care Management (ECM) provides person-centered, community-based care management to Medi-Cal members with the highest needs. In this CalAIM initiative, members are assigned a Lead Care Manager who meets them where they are to coordinate all their health and health-related care. 

  • Outreach and engagement.  
  • Comprehensive assessment and care management plan.   
  • Enhanced coordination of care.   
  • Health promotion.   
  • Comprehensive transitional care.   
  • Member and family supports.   
  • Coordination of and referral to community and social support services. 

ECM Serves the Following Populations of Focus (POF):   

 

  • Adults without Dependent Children/ Youth Living with Them Experiencing Homelessness  
  • Homeless Families or Unaccompanied Children/ Youth Experiencing Homelessness  
  • Individuals At Risk for Avoidable Hospital or Emergency Department (Formerly “High Utilizers”)  
    • Adults  
    • Children & Youth  
  • Individuals with Serious Mental Health and/or Substance Use Disorder (SUD) Needs  
    • Adults  
    • Children & Youth  
  • Individuals Transitioning from Incarceration   
    • Adults  
    • Children and Youth  
  • Adults Living in the Community and At Risk for Long Term Care (LTC) 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 CCS Condition  
  • Children and Youth Involved in Child Welfare  
  • Birth Equity  
    • Adults  
    • Children and Youth   

Community Supports

Community Supports (CS) are services provided by Managed Care Plans to address Medi-Cal members’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care.

  • Housing transition navigation services   
  • Housing deposits   
  • Housing tenancy and sustaining   
  • Short-term post-hospitalization housing   
  • Recuperative care (medical respite)   
  • Respite services   
  • Day habilitation programs   
  • Nursing facility transition/diversion to assisted living facilities   
  • Community transition services/NF transition to a home   
  • Personal care and homemaker services   
  • Environmental accessibility adaptations (home modifications)   
  • Meals/medically tailored meals   
  • Sobering centers   
  • Asthma remediation  

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