Cal AIM: California Shise Promise Health Plan CMO Explains Medi-Cal Transformation | California Blue Shield

In January, California health plans offering Medi-Cal coverage began to be implemented in the first year of the state’s CalAIM program, an ambitious multi-year plan to transform the Medi-Cal program and improve the health outcomes of Medi-Cal populations. “This transformation is long overdue and a major change in the way health care is perceived and delivered. Enrolled in Medi-Cale will provide access to important non-medical services [social services] “These transformations will benefit the physical and mental health of our 450,000 Medi-Cal members.” and, knowing that, fosters a passion to do everything we can to ensure the success of CalAIM, ”he said.

Dr. James Cruz

In this column, Dr. Cruz answers questions about CalAIM’s comprehensive efforts, which will affect Medi-Cal members and health plans.

What is CalAIM and why was it created?

California Advancing and Innovating Medi-Cal (CalAIM) is a five-year plan led by the California Department of Health Services to transform and strengthen Medi-Cal and improve the overall health outcomes and overall well-being of Medi-Cal enrollees. with the most complex needs. Our team is committed to ensuring that we meet all of the regulatory criteria and deadlines as we roll out additional services for CalAIM in the coming years. We understand the positive results that this will bring to the lives of our members and to Medi-Cal as a health safety network.

CalAIM was designed as a vision for population health to provide a simplified, consistent, and coordinated system of preventive care for all people, and extends traditional care directly beyond hospitals and health facilities to California communities. Simply put, CalAIM examines the direct link between the deficiencies in the social needs of the population and the multiple factors that determine health outcomes. The plan expands and incorporates non-medical services into the health system that address social health conditions such as housing, transportation, nutrition, and caregiving.

What complex medical needs will CalAIM address for Medi-Cal members?

We know first hand that members of Medi-Cale have complex needs and are diverse. Our teams working with Medi-Cal members understand the significant issues they face, and how coordinated health and social service interventions can help them. These members include serious mental illness, substance abuse, or emotional distress; the elderly and the disabled; homeless people with complex health needs; Former inmates who are in transition to the community with complex physical or behavioral needs; children with complex diseases such as cancer, epilepsy and congenital heart disease, and children and young people in foster care.

How long will it take to fully implement CalAIM in California?

The Medi-Cal transformation will take place in five years. The first reforms were launched in January this year, and ongoing transformations will be implemented every year until December 2027.

What changes will Medi-Call members, healthcare organizations and social service agencies make?

This year, some non-medical care provided to people at risk will now be integrated into the CalAIM system.

There are many examples of the importance of providing comprehensive support to members at risk, which can significantly improve their results, but here is one:

According to CalAIM, 18 new health codes have been programmed into the Medi-Cal system, and currently allow community organizations working with health plans to provide non-essential medical services to Medi-Cal members, such as hotel rooms or travel arrangements. members who need medical procedures that are not close to their home.

What are some of California’s most important challenges to CalAIM’s success?

There are many challenges when we implement our industry CalAIM. To successfully meet them, health plans, physicians, hospitals, state officials, and community-based organizations will need to work closely together with transparency and open-mindedness. Here are two examples of the challenges of transforming Medi-Cal:

  • Lack of resources to provide social services and support to people at risk in their communities: Making the CalAIM approach a reality will require significant collaboration between health plans, providers, community agencies, and the state to develop a strong pipeline for health care professionals (nurses, community health workers, and others) who can provide full access to care. necessary. Innovative approaches are already in place.

An example is the California Assembly Bill-890, which expands the ability of a professional nurse to comply with specific provisions for practicing on her own. With this bill in place, nurses will no longer have to work under the direct supervision of a physician and medical practitioner. This means that they will be able to expand the network of medical professionals available to serve populations that benefit from the set of medical skills of the nursing professional. The California Registered Nursing Board expects the AB 890 implementation to take place on or before January 1, 2023.

  • Occasional patient data: Today, our healthcare industry does not have enough up-to-date patient data to share the full record of patients across the healthcare system. There is no strong, statewide exchange of health information across California that allows for the safe, secure, and rapid sharing of information between hospitals and providers that can be used in a variety of ways that can benefit patients, especially in life-threatening situations.

How will CalAIM affect Blue Shield Promise and other California health plans?

Overall, I think it will have a positive impact on Blue Shield Promise and other California health plans. We will see greater use of Medi-Cal health services because people will be identified early, through their needs, through our collaboration with outside community organizations and other involved vendors. It is important to identify people with unmet needs through us. as the support network expands, we can quickly see where the differences are. This will help us develop strategies and programs to improve services for the affected population so that they do not fall behind in getting the care they deserve. That’s what CalAIM is all about.


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