Cal AIM: CMO’s Blue Shield of California Promise Health Plan Explains Medi-Cal | Transformation The Blue Shield of California

In January, California health plans that offer Medi-Cal coverage began implementing the first year of the state’s CalAIM program, an ambitious, multi-year plan to transform the Medi-Cal program and improve health outcomes for the Medi-Cal population. “This transformation is coming a long time ago and is a major change in the way health care is perceived and provided. This will enable Medi-Cal subscribers to receive important non-medical services [social services] which complement their regular health care and support their well-being, ”explained James Cruz, Ph.D. and Chief Medical Officer of the Blue Shield of California Promise Health Plan. “This transformation will benefit the physical and mental health of our 450,000 Medi-Cal members and, knowing this, fuels our 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 both Medi-Cal members and health plans.

What is CalAIM and why was it created?

California’s Medi-Cal Progress and Innovation (CalAIM) is a five-year plan led by the California Department of Health to transform and strengthen Medi-Cal and improve the health outcomes and overall well-being of Medi-Cal enrollment, especially those with the highest complex needs. Our team is deeply committed to ensuring that we meet all regulatory criteria and deadlines as we implement additional CalAIM services over the next few years. We understand the positive results this will bring to the lives of our members and our role in their Medi-Cal healthcare network.

CalAIM is designed as a public health approach to providing a streamlined, consistent, and coordinated system of preventive care for the whole person and extends traditional care outside of hospitals and health facilities directly to communities in California. Simply put, CalAIM deals with the direct link between the deficits of the social needs of the population and the many factors that determine the results of health care. The plan expands to include non-medical services in the health care system that address the social determinants of health such as housing, transport, nutrition and supportive care.

What complex medical needs of Medi-Cal members will CalAIM respond to?

We know first hand that Medi-Cal members have complex needs and are a diverse group. Our teams working with our Medi-Cal members understand the significant issues they face and how coordinated medical and social interventions can help them. These articles include people with significant mental illness, substance abuse problems or emotional disorders; elderly people and others living with disabilities; homeless people with complex physical or behavioral health needs; ex-detainees moving to the community who have complex physical or behavioral needs; children with complex medical conditions 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 transformation of Medi-Cal will take place in five years. The first reforms started in January this year, and the current transformations will be carried out in stages each year until December 2027.

What early changes will Medi-Cal members, healthcare organizations and social service agencies experience?

This year, some types of non-medical support that were previously provided on an ad hoc basis for people at risk will now be integrated into the CalAIM system.

There are many examples that show how important it is to provide comprehensive support to members at risk that can significantly improve their performance, but here is one:

According to CalAIM, 18 new health codes have been programmed into the Medi-Cal system, which already enables community-based organizations working with health plans to provide critical non-medical services to Medi-Cal members, such as hotel rooms or arranging travel for members in need of medical procedures not located near their home.

What are the key challenges facing California to make CalAIM a success?

There are many challenges facing our industry as we implement CalAIM. To meet them successfully, health plans, doctors, hospitals, government officials and community organizations will need to work closely together, with transparency and openness. Here are two examples of the challenges in transforming Medi-Cal:

  • Lack of resources to provide social services and support that people at risk need in their communities: Making CalAIM’s vision a reality will require remarkable collaboration between health plans, providers, community-based and state-based agencies to develop a strong channel of health professionals – nurses, community health professionals and others – who can provide full access to care required. Innovative approaches are already underway.

One example is the California Assembly Bill 890, which expands a nurse’s ability to practice independently once certain specific provisions are met. With this bill, nurses will no longer have to work under the direct supervision of a doctor and a medical practitioner. This means that they will be able to expand the network of health professionals to serve populations that can benefit from a practicing nurse’s skill set. The California Board of Registered Nurses expects AB 890 to be administered on or before January 1, 2023.

  • Timely patient data: At present, our healthcare industry does not have enough up-to-date patient data to allow the sharing of complete patient files across the healthcare system. California lacks a stable state-wide exchange of health information that allows information to be safe, secure, and quickly shared between hospitals and providers, allowing them to use that data in a variety of ways that can benefit patients, especially in life-threatening situations.

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

Overall, I believe the impact will be positive for the Blue Shield Promise and other health plans in California. We will see greater use of Medi-Cal’s health services, as people will be identified early because of their needs, through the partnerships we have with external community-based organizations and other participating providers. It is important that by identifying people with unmet needs through our extensive network of support services, we will be able to quickly see where there are inequalities. This will help us develop strategies and programs to improve services for affected populations so that they do not lag behind in receiving the care they deserve. Ultimately, this is the goal of CalAIM.

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