Health Data Exchange, Care Coordination to Support Medi-Cal in 2022

A better health data exchange and care coordination technology solution is going to support the California Department of Health Care Services (DHCS) as it launches a program designed to address the multifaceted needs of Medi-Cal’s most vulnerable members.

The California Advancing and Innovating Medi-Cal (CalAIM) program is set to enhance health data exchange among managed care plans (MCPs), county agencies, and providers by establishing two new benefits: Enhanced Care Management (ECM) and In Lieu of Services (ILOS).  

The ECM benefit will provide whole-person care management and coordination to Medi-Cal members with complex clinical and nonclinical needs.

MCPs will administer and oversee ECM benefits by identifying members in each of the ECM target populations and assigning them to “ECM providers.” These clinicians will be responsible for patient outreach and care coordination across an array of physical, behavioral, and social service providers.

ECM services will be community-based, allowing patients to frequently connect with their ECM providers face-to-face.

DHCS’ second upcoming benefit, ILOS, will allow patients to substitute existing State Plan–covered services with health-supporting services that may reduce costs, mitigate social determinants of health, and drive down hospitalizations and institutionalizations.  

DHCS will allow 14 separate ILOS categories, which include housing transition and navigation services, respite care, day habilitation programs, and nursing facility transition support to assisted living facilities or a home.

MCPs will be able choose which ILOS to cover and control which counties and members can access the services.

At the crux of this mission will be a health data exchange system to coordinate care across disparities healthcare and social services providers.

The new program will engage a broad set of MCPs, providers, county agencies, and community-based organizations (CBOs). Many of these organizations, especially CBOs, have limited health IT infrastructure and bandwidth, which prevents them from interacting extensively with the healthcare system.

Participation in the program offer better interoperability, providing CBOs the ability to share and use administrative, health, and social service information to fulfill ECM and ILOS program functions.

ECM providers will be able to use data acquired from the MCP, the member, and other sources, to develop a comprehensive care plan available for use by a member’s care team.

ECM providers will also support transitional care, care coordination, and referral management by engaging with MCPs’ referral network for community and social services, including ILOS.

ECM and ILOS providers will record and report services rendered to MCPs, and MCPs will then report encounters of all services provided to DHCS. To track the program’s health and economic impact on Californians, MCPs will report DHCS-specified quality and performance metrics.

The report authors outlined a road map for policymakers, government agencies, MCPs, and providers that issues recommendations on how to address data, data exchange, and health IT system barriers to implementing the ECM and ILOS program functions.

The road map recommendations address three barriers to patient data exchange: regulations, infrastructure, and financing. The authors give several actionable steps for stakeholders to mitigate these data exchange barriers.

For instance, state legislators should pass regulations and policies to facilitate safe and secure information sharing in support of CalAIM and Medi-Cal program objectives, the authors noted.

“Whole-person approaches to care require all parties in a community to step outside of their traditional boundaries to provide a level of collaboration and coordination that addresses drivers of health,” the report authors wrote.