CalAIM Overview

About CalAIM

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

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. 

ECM Core Services

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.

Populations of Focus

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.

Community Supports Offered Through CalAIM

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

About CalAIM

CalAIM Overview

Enhanced Care Management

Community Supports

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