Developing Services and Workforce in Response to the California Advancing and Innovating Medi-Cal (CalAIM) Initiative: Learnings from Primary Care Clinics and Their Partners in the ACEs Aware PRACTICE Collaborative

Table of Contents

• Developing Services and Workforce in Response to the California Advancing and Innovating Medi-Cal (CalAIM) Initiative 1
• About RAND 2
• Research Integrity 2
• Limited Print and Electronic Distribution Rights 2
• About This Report 3
• Acknowledgments 4
• Summary 5
• Key Findings 5
• Key CalAIM Services 7
• Evaluation Approach 8
• PRACTICE Learning Lab Findings 9
• Overall Findings 9
• Findings in Key Domains Required to Start and Sustain CalAIM Services 9
• Contracting. 9
• Workforce. 9
• Implementation. 10
• Impact of CalAIM Services on Providers and Patients 11
• Assistance and collaboration. 12
• Billing, reimbursement, and sustainability. 12
• PRACTICE Collaborative Overall Evaluation Findings 13
• Recommendations 14
• Recommendations for Clinics and CBOs Considering Implementing Key CalAIM Services 14
• Contracting with MCPs for CalAIM services. 14
• Building and expanding the workforce for CalAIM services. 14
• Implementing CalAIM services. 14
• Engaging patients in CalAIM services. 15
• Billing and reimbursement for CalAIM services. 15
• Recommendations for Policymakers to Support Implementation of Key CalAIM Services 16
• Conclusion 17
• Contents 18
• Figures and Tables 18
• Figures 18
• Tables 18
• CHAPTER 1 Introduction 19
• Background 19
• Key State Milestones 20
• PRACTICE Context 21
• The PRACTICE Collaborative 22
• Key CalAIM Benefits 23
• Approach 24
• Navigating This Report 25
• CHAPTER 2 Methods and Data Sources 26
• Detailed Syntheses of the Implementation Process and Progress Toward Sustainability of Four Key CalAIM Benefits 27
• In-Depth Interviews with a Subset of Clinics and CBOs 28
• Content. 28
• Data collection. 28
• Interviews with Patients Receiving Services from a Subset of Clinics and CBOs 28
• Content. 28
• Data collection. 28
• Analysis 28
• Evaluation of the Overall PRACTICE Collaborative 29
• Periodic Reports 29
• Content. 29
• Data collection. 29
• Analysis. 29
• Surveys 30
• Baseline Survey 30
• Content. 30
• Data collection. 31
• Analysis. 31
• Follow-Up Survey 31
• Content. 31
• Data collection. 31
• Analysis. 31
• Early and Mid-Implementation Interviews with Clinics, CBOs, and MCPs 32
• Content. 32
• Data collection. 32
• Analysis. 32
• Learning Collaborative Data 32
• CHAPTER 3 Implementation and Sustainability of Adult Enhanced Care Management 33
• Background and Context 34
• History with adult ECM. 34
• Motivation for pursuing adult ECM. 34
• Managed Care Plan Contracting 35
• How did they do it? 35
• Persistence and exhaustive outreach to the MCP facilitated contract execution 35
• MCPs and clinics were learning together in early stages of contracting 36
• Workforce 36
• How did they do it? 36
• Staffing. 36
• Training and education. 37
• Credentials and certifications. 37
• Planning for the workforce pipeline 37
• Implementation 38
• How did they do it? 38
• Policies and workflow. 38
• Data systems and electronic health records (EHRs). 39
• Referral processes and service delivery. 39
• Patient engagement. 41
• Normalizing ECM support increased patient acceptance 43
• Being a one-stop shop in the community helps with engagement and trust 43
• ECM providers were there when you needed them most 43
• Patient perspective: ECM providers checked in regularly 43
• Assistance and Collaboration on Implementation 44
• How did they do it? 44
• Billing and Reimbursement 45
• How did they do it? 45
• Delayed reimbursements hindered the ability to hire additional adult ECM providers 47
• Moving to per-member-per-month billing has been challenging 47
• Patient contact reporting is burdensome 47
• Impact on Patients and Providers 48
• How did adult ECM affect patients, clinicians, and staff? 48
• Patients had positive experiences with ECM 49
• Clinician perspective: Adult ECM allows me to do my job better 50
• Leader perspective: Adult ECM takes stress away from other clinic members 50
• Provider perspective: Adult ECM empowers patients 50
• Sustainability 51
• What was needed to sustain it? 51
• Financial sustainability. 51
• Workforce sustainability. 52
• Financial sustainability can be hard to assess 53
• Financial sustainability was only part of the consideration 53
• CalAIM ECM benefits provide funding and infrastructure for future efforts 53
• Workforce sustainability: Burnout and support 54
• Provider perspective: Having multiple roles can be difficult for providers 54
• Additional Advice for Implementation of Adult ECM 54
• Clinics Wanted Mechanisms to Support Lower-Acuity Patient Needs 54
• There was a need for options to support lower-acuity patients 55
• Clinics Beginning Adult ECM Implementation Need Clearer Guidance on Reimbursement and Eligibility 55
• Improved guidance on policies and requirements would improve implementation 56
• Inaccurate MCP Referrals Create Additional Burdens for Clinics 56
• CHAPTER 4 Implementation and Sustainability of Pediatric Enhanced Care Management 57
• Background and Context 58
• History with pediatric ECM. 58
• Motivation for pursuing pediatric ECM. 58
• Managed Care Plan Contracting 59
• How did they do it? 59
• Pediatric ECM contracting was easier because it came after adult ECM 59
• Workforce 60
• How did they do it? 60
• Staffing. 60
• Training and education. 61
• Credentials and certifications. 61
• Clinics looked within their ranks to develop a new workforce 61
• Implementation 62
• How did they do it? 62
• Policies and workflows. 62
• Data systems and EHRs. 63
• Referrals and service delivery. 63
• Patient engagement. 64
• Caregivers of pediatric ECM patients appreciated the help 65
• ACEs are confirmatory and provide context for referral to pediatric ECM 65
• Changing EHR systems can be a long process 66
• Bilingual pediatric ECM providers helped build trust 66
• Assistance and Collaboration on Implementation 66
• How did they do it? 66
• Internal collaboration was vital to support program implementation 67
• Billing and Reimbursement 67
• How did they do it? 67
• Small differences in reporting requirements created substantial administrative burden 68
• Impact on Patients and Providers 68
• How did pediatric ECM affect patients and caregivers, clinicians, and staff? 68
• Caregivers of pediatric ECM patients found that pediatric ECM helped support their families 69
• Providers perceived significant improvements in patients receiving pediatric ECM 70
• Sustainability 70
• What was needed to sustain it? 70
• Financial sustainability. 70
• Workforce sustainability. 71
• There is a mismatch between the eligibility criteria and the reimbursement rate 72
• CalAIM funding has replaced some of the grant funding for case management 72
• Some clinics are pausing ECM expansion 72
• Additional Advice for Implementation of Pediatric ECM 73
• Clinics Wanted Mechanisms to Support Lower-Acuity Patient Needs 73
• Workflows Were Easier for Pediatric ECM Than for Adult ECM 73
• Pediatric ECM can be easier than adult ECM 74
• CHAPTER 5 Implementation and Sustainability of Community Health Worker Services 75
• Background and Context 76
• History with CHW services. 76
• Motivation for pursuing CHW services. 76
• Partnering during the start-up process. 76
• Managed Care Plan Contracting 77
• How did they do it? 77
• MCPs were sometimes selective when contracting for the CHW benefit 77
• Workforce 78
• How did they do it? 78
• Staffing. 78
• Training and education. 79
• Credentials and certifications. 79
• Clinics worked to find CHWs with lived experience that fit with the patient population 80
• Implementation 81
• How did they do it? 81
• Policies and workflows. 81
• Data systems and EHRs. 81
• Referrals and service delivery. 81
• Patient engagement. 82
• CHWs who made themselves accessible successfully built trust with families 83
• Assistance and Collaboration on Implementation 84
• How did they do it? 84
• Billing and Reimbursement 85
• How did they make progress? 85
• Patients appreciated all modalities of CHW engagement, but only in-person and phone encounters were reimbursable 86
• The CHW benefit is flexible; referral does not require specific tools or assessments 86
• Impact on Patients and Providers 87
• How did CHWs affect patients, clinicians, and staff? 87
• CHWs had a positive impact on patients and clinicians 88
• Sustainability 89
• What was needed to sustain it? 89
• Financial sustainability. 89
• Workforce sustainability. 90
• Current CHW benefit reimbursement rates are unsustainable 90
• Clinics valued CHWs even if they were not financially sustainable 90
• Additional Advice for Implementation of CHW Services 91
• Effective Collaboration Was a Cornerstone for Successful Implementation 91
• Ensuring Buy-In and Support for CHW Services at All Levels—from Leadership to Clinicians—Was Imperative for Integration and Sustained Success 91
• CHAPTER 6 Implementation and Sustainability of Dyadic Services 92
• Background and Context 93
• Motivation for pursuing dyadic services. 93
• Managed Care Plan Contracting 94
• Workforce 94
• Clinic Workflow 94
• Pediatricians’ knowledge of the families they serve has been critical to successful referrals 95
• Providers leveraged in-person visits and follow-ups to increase impact 95
• Providers promoted patient engagement by normalizing the services 95
• Assistance and Collaboration on Implementation 96
• Clinics took advantage of existing resources to streamline implementation 96
• Billing and Reimbursement 96
• Impact on Patients and Providers 96
• Clinics are finding that patients have a great deal of interest in dyadic services 97
• Information provided to families helps them feel prepared to meet their child’s needs 97
• Sustainability 97
• PRACTICE provided the resources the clinic needed to better serve their patients 98
• Additional Advice for Implementation of Dyadic Services 98
• There Were Benefits and Drawbacks to Utilizing an Existing Model of Dyadic Service Delivery 98
• The lack of support from the HealthySteps model developers was frustrating 99
• FQHCs Considering Dyadic Services Should Delay Implementation Pending a Change in the Prohibition Against Same-Day Billing for Dyadic Services 99
• For FQHCs, it would be better to wait for billing to be resolved before implementing 99
• CHAPTER 7 Findings from the Evaluation of the PRACTICE Collaborative 100
• Groundwork for Developing CalAIM Services 101
• ACEs Aware Core Training During PRACTICE 101
• Organizational Readiness for Trauma-Informed Health Care 101
• ACE Screening and Referrals During PRACTICE 102
• Progress Toward PRACTICE Goals 103
• Strengthening PRACTICE Partnerships 103
• MCPs recognized the importance of clearly defining roles and responsibilities 104
• Teams successfully collaborated to enhance workflow and learning 104
• Early inclusion and strategic partner selection are important for successful collaboration 105
• Expanding Workforce During PRACTICE 105
• CBOs were hired from the community to leverage local knowledge and trusted relationships 106
• A community-driven and member-centric staffing approach can address workforce shortages 108
• Effective planning and clear roles for staff can improve quality and efficiency of care 108
• Developing Services During PRACTICE 108
• Teams found that flexibility and preparation could facilitate implementation 109
• Implementation Status of CalAIM Services 110
• Plans for Sustaining CalAIM Services 111
• Sustainability can be difficult due to complex billing structures 112
• Securing funding for new workforce presents challenges 113
• Impact of CalAIM Services 113
• Summary of Evaluation Findings 115
• CHAPTER 8 Discussion and Recommendations 116
• Discussion 116
• Evaluation Limitations 121
• Recommendations 122
• Recommendations for Clinics and CBOs Considering Implementing Key CalAIM Services 122
• Recommendations for Policymakers to Support Implementation of Key CalAIM Services 125
• Conclusion 126
• Abbreviations 127
• References 128