Senate Standing Committee on Budget and Fiscal Review

The Senate Budget and Fiscal Review Committee will, I don't know if anybody heard that gavel the first time, will now come to order. And we will be holding the hearing here in room 1200, and we will take public comment both from people who are here in the hearing room and also on a phone line. So the teleconference participation number and one second, I'm not sure if I have the right one, Elisa, because I'm looking at my old script. Here we go. Okay, it's cool.

I got it now. I just want to make sure I had the correct number. Today's participant number is 877-226-8163 the access code is 4400595 and I will maintain decorum as is customary. Anyone who is disruptive could be removed from the remote meeting service or have their connection muted. The folks who are providing testimony today to us are participating remotely. And remote participants, you know the drill. Please say your name. You have to unmute yourself.

Please identify yourself before you speak, and then our tech will mute you when you're finished. And if you wish to respond to any of our Members' questions, use the raise your hand feature, and I will see that and call on you. We will have our public comment after all the discussion items have been presented.

And, Members, I'll explain how I want to handle this today because as you can see, we have a number of panels and a lot of speakers, so I'll discuss that in a moment. Let me see if I have a quorum yet. Okay, so let us call the roll.

[Roll call] We have a quorum.

We now have a quorum. So let me give you some little opening comments so we know how we're proceeding today. This is our third informational or oversight hearing of the budget committees that we've convened so far this month. And as we're all aware, last year, the last two years, the state's revenues were substantial, which enabled us to direct a higher than usual amount of funds to a variety of programs.

And we've been holding these hearings to get a little bit more in depth on those things that we have been increasing the funding for so that we can see how it is being implemented within our communities and also identify any issues that our agencies or others are confronting in doing this money.

Now, one of the large, very substantial things that we did in the last couple of years is embrace a new initiative of Medi-Cal called CalAIM, which is the California Advancing and Innovating Medi-Cal. And this transformative reorientation of Medi-Cal is a healthcare program that addresses the needs of the whole person.

It's been under development for more than four years, but we've really been launched in terms of our providers being able to access it and our Medi-Cal recipients being able to benefit from it much very recently. So our hearing today will provide updates to implementation of the key components of CalAIM, with a particular focus on the new enhanced care management and community supports benefits.

So those community supports benefits include things like being able to provide six months rent for someone, for example, or in effect, a prescription for food, if that is what that medical recipient most needs in terms of dealing with their health conditions. So there's a variety of things like that, which we will learn about. CalAIM is wide ranging and ambitious.

And so we are trying to get into the weeds a bit on it, and that's why we have such a number of panels and a large number of panelists. So what I'm going to ask today is that you hold your questions until we've heard from all the panels and that you think carefully as you listen to them, and that when I call on you when we do questions, I'll ask you to do two questions only in that initial take so that we can get everybody.

And then I'll come back to you if you have more questions. Does that help? Hopefully then we can get through everyone that we have in mind today. All right. So now we will go to our first panel, sorry, I have a lot of papers in front of me. All right. So this initial panel is an overview of CalAIM's implementation. And we have on the panel Melora Simon, who is the Associate Director of People Centered Care for the California Health Care Foundation.

And I just note, Members, that either after this hearing, if you want to get a little more in depth for a variety of things related to CalAIM, the California Healthcare Foundation website has a number of reports related to CalAIM. So I recommend that as a resource. So we will hear from Melora Simon. We will also hear from Michelle Baass, who is the Director of the Department of Healthcare Services. And in this initial panel, she'll just give introductory remarks.

And then Jacey Cooper, who is the Chief Deputy Director and California Medicaid Director from the Department of Health Care Services. So let us start with Melora Simon. Go ahead.

Thank you. Good morning, Madam Chair, Mr. Vice Chair and Members of the Committee. Thank you for inviting me to speak today on this important topic. My name is Melora Simon and I work at the California Healthcare Foundation, where I am an Associate Director on the Advancing People Centered Care team. For those of you not familiar with the foundation, CHCF is an independent, nonprofit philanthropy that works to improve the healthcare system so that all Californians have the care they need.

We're especially focused on making sure the health system works for Californians with low incomes and for the communities who have traditionally faced the greatest barriers to care. Today, I'm going to put CalAIM in context by talking about our Medi-Cal delivery systems, and then I'm going to go a little bit deeper on health and homelessness, given its importance in the state. So let's start with Medi Cal.

It's probably worth a reminder that our Medi-Cal program is, after Medicare and the VA, the biggest public health program in the country. It covers one in three Californians, half of births, half of school aged children, half of people with disabilities, and two thirds of long term care days. And there are two things that are important to note about Medi-Cal. One, it's very comprehensive when it comes to healthcare. And two, it's not a single program.

So for physical health care, Medi-Cal is mostly administered by Medicaid managed care plans. Unless, of course, you are one of the 1.6 million Californians that are duly eligible for both Medicare and Medical, then your physical health care is covered by Medicare. For mental health care, services are split between managed care plans, which handle non-specialty mental health care, and county mental health plans, which handle specialty mental health care. County behavioral health also handles substance use services, often through a separate managed care plan.

But some things are handled centrally, like prescription drugs and dental care. Personal care services, known in California as IHSS, are handled by yet another state agency and administered by counties, as are services for kids with special health care needs. And there are many small, specialized programs designed to help people who might otherwise be in nursing homes stay in the community.

Most of these are managed in the Fee-for-Service system, though a few critically long term care and nursing homes as of 2023 are handled by managed care plans.

So a metaphor that comes to mind for me with Medi-Cal is that imagine that instead of going to a single store to go food shopping, you have to not only go to different stores to get proteins, fruits, grains and vegetables, but you have to pay with different cards and navigate different rules about what you could buy, when and from whom.

And not all stores would take your cards, and that wouldn't be so bad if you were making something simple like a grilled chicken dinner, but now trying to get everything you need to feed your family for a week and you're taking public transportation in a wheelchair and English isn't your first language. In addition, many medical beneficiaries face other social risk factors that we know are very important to our overall health and well being.

That sometimes results in our system paying more downstream rather than making a small upfront investment. A classic example is that before CalAIM, Medi-Cal would pay for the ER visit to resolve an asthma attack, but not the mole removal that would eliminate the allergens that triggered the attack. So what does this complex system deliver in terms of access? When Medi-Cal managed care members are surveyed about their experience, one in four says they can't consistently get what they need in a timely manner.

This puts our managed care system in the bottom quartile nationally. These themes around access also show up when we hear directly from consumers. CHCF believes that our healthcare system, especially public programs like Medi-Cal, should reflect the needs, experiences and priorities of the people they serve. With that in mind, we engage in what we call 'listening work' to help policymakers and healthcare partners understand the experiences and attitudes of healthcare consumers. These quotes come from that work.

Moving away from access and talking about quality, California actually performs very, very well on most quality measures. However, when you look at measures that require coordination or proactive outreach or handoffs between systems, Medi-Cal falls below national benchmarks. On this chart, the blue bar is California's performance and the gray bar is how far we are from the national median. For example, only 7.6% of people who are seen in the ED for substance use disorder have follow up within seven days, the national median is double that.

And when you start to break down the quality of performance by race and ethnicity, there are significant inequities in the quality of mental health care, in preventive care, and in physical health care for chronic diseases like diabetes. So we have a lot of work to do on equity, and in the main, it's performance failures like these in the complex system that we have that CalAIM is designed to address.

CalAIM is about all Medi-Cal enrollees, but many of its best known reforms focus on people with complex needs, known in CalAIM parlance as populations of focus. There are millions of people within this category, and their needs are often intersectional. This slide attempts to put a size around them and show how there are different overlaps and intersections between them.

You'll hear a lot more about the specific of CalAIM's programs from DHCS. Taking a long view of the Medi-Cal program and its history, here are some areas where we think CalAIM has the potential to address some long standing issues in Medi-Cal that are important for all enrollees: lower payment rates relative to Medicare, weak incentives for managed care performance, lack of a standardized approach to population in managed care, which makes comparisons and oversight quite difficult and inconsistent oversight across systems.

CalAIM also has the potential to address issues that get in the way of advancing people centered care and has a myriad of programs and reforms for people with complex needs. These reforms seek to address the historical lack of accountability between the complex systems that we heard about in which people fall through the cracks and have trouble navigating them. Misaligned incentives across the system where wrong pockets problems arise.

These arise when one organization is best placed to make an investment, but it's another organization, another pocket that benefits from the investment. This tends to result in underinvestment, poor coordination at times of transition, like discharge from the hospital or nursing home after a health crisis or released from jail after an arrest. It's worth a reminder that 1 million people cycle through California's jails and prisons, 80% of them are eligible for Medi-Cal and upwards of 40% have behavioral health needs.

Closing out our section on Medi-Cal, I have a few slides that talk about the intersection between health and homelessness. Of course, experiencing homelessness itself is traumatic, but it's important to remember that it can also take a terrible toll on people's physical and mental health. In fact, more than 125,000 people, almost half of all people experiencing homelessness in 2021, reported having a long term disabling condition.

And the unhoused population with these conditions continues to grow, up 75% since 2017 and growing 50% faster than the growth in the overall unhoused population. It's also worth noting that more than 40% of people experiencing homelessness are either under 18 or over 55. These mental and physical health conditions, among other factors, contribute to the fact that people experiencing homelessness are hospitalized at five times the rate of their housed peers. These hospitalizations disproportionately impact black and American Indian Alaska Native populations.

While I've talked about this largely in terms of numbers and facts, at the end of the day it's about people. We've pulled together some stories to help bring the numbers to life, and I encourage you to listen to some of them to better understand why this work is so important. In closing, successful implementation of CalAIM is critical to making sure people like Rosalind get the care they need when they need it. Thank you again for the opportunity to speak to you today.

Melora, thank you. As I indicated when we opened, this panel is going to give us the high level, comprehensive overview of the CalAIM initiative. So I really appreciated the depth that you went into. And we'll now hear from Michelle Baass, who's the Director of the Department of Health Care Services. Michelle.

Good Morning, Madam Chair and Members. Michelle Baass, Director of the Department of Healthcare ServIces. Thank you for the opportunity to be here today to provide a brief overview of CalAIM and thank you for your support and partnership on CalAIM. CalAIM is our long term initiative to improve health outcomes and equity through Medi-Cal delivery system and payment reforms implemented over a number of years.

One of our top priorities is to deliver high quality care by improving and streamlining the Medi-Cal experience for the Californians the program serves. As very comprehensively outlined in your hearing materials and as State Medicaid Director Jacey Cooper will speak to in detail, CalAIM includes initiatives that address members with complex needs, looks upstream to prioritize prevention and whole person care, strengthens the state's behavioral health continuum of care for all Californians, and promotes better integration with physical health care, and addresses poor health outcomes in disproportionate risk of illness and accidental death among justice involved Medi-Cal eligible adults and youth as they reenter their communities.

As just examples, members with complex needs will have their health care and health related services coordinated through enhanced care management and will also have access to community supports which address many of the social drivers of health such as housing transition navigation services, diversion to assisted living facilities, personal care and homemaker services, and medically supportive meals. We're also moving Medi-Cal toward a population health approach that prioritizes prevention and whole person care for members throughout their lives.

This approach extends supports and services beyond hospitals and healthcare settings directly into California's communities. The behavioral health components of CalAIM are designed to support whole person integrated care and move the Administration of Medi-Cal behavioral health to a more consistent and seamless system by reducing complexity and increasing flexibility. These reforms complement the significant infrastructure investments such as the Behavioral Health Continuum and Infrastructure program, behavioral health bridge housing, and the Children and Youth Behavioral Health Initiative.

We are changing the way we provide care, getting into the communities and engaging with nontraditional providers, working upstream and with our community providers to wrap health and health-related services. To do this, we are investing significant resources in the building up of this community infrastructure through path because we know that if we are truly going to address the social drivers of health, we need to bring new community based providers into the program. We won't address equity unless we do so.

Together with our managed care plan partners, we hope to set a new standard of care that can serve as a model. We are currently going throughout the state on a listening tour to hear from our implementation partners how things are going, what's working and what is challenging.

What struck me last week at one of our meetings, which are convened by our Medi-Cal managed care plans, was that in addition to the normal healthcare partners, hospitals, clinics, provider groups, the county Superintendent of Education, the Sheriff's office, probation, First 5, the local public health department, Social Services Department, county workforce department, senior services were in attendance. This transformation is pulling together local partners that use different languages and have traditionally worked independently.

This is the future of Medi-Cal and why our new Medi-Cal Managed Care contract that goes into effect in 2024 is integral to this transformation. The new contract is raising our expectations of medical managed care plans, creating more transparency, accountability, equity, quality and value, which will in turn translate into better health outcomes. With CalAIM's opportunity for transformation and our new contract with our managed care plans, we are at a pivotal time in the Medi-Cal program.

We are pushing outside of healthcare's four walls and promoting better partnership and integration with other sectors which ultimately will lead to better outcomes from our members. Thank you for the opportunity to be here today.

Ms. Baass, thank you very much for that. And now we will hear from Jacey Cooper, who is the Chief Deputy Director and California Medicaid Director from your department.

Good morning. As Michelle mentioned, CalAIM encompasses a very broad based delivery system program and payment reforms, and I will have the opportunity to walk through at a high level some of those initiatives, but I look forward to the back and forth dialogue given the overview will be high level. One thing I want to emphasize when it comes to CalAIM, since it is a large transformation, as Michelle clearly outlined, it is meant to be implemented over multiple years, and that's an important thing for us to remember.

The initiative is large, it's complex, and it's really meant to build on year over year policy. So now I will provide an overview of the various CalAIM initiatives and an update of where we are on those various initiatives. One of the cornerstones of CalAIM is really the Population Health Management Program that uses evidence based practices and data analytics to close gaps in care and drive delivery system activation to improve outcomes.

It's really focused on many of the things that were just outlined by CHCF, and that's really the backbone of what we're doing, population health management, is about engaging members as owners of their own care through preventative care, early interventions for rising risk, patient centered disease management, and implementing holistic care for our high risk populations, including addressing social drivers of health.

It also redesigns critical transitions in care, whether that's from jails or from an institutional level of care, back into the community, making sure that our full continuum is working as intended. To support the population health management program, DHCS is developing a population health platform as well, essentially an analytical backbone that will give members access to their own data as well as plans, providers, and partners. The ability to access integrated data across Medi-Cal as we all know, Medi-Cal can seem siloed and separated.

We have lots of different systems of care for one person, and we want to bring all of that data together for people. The Population Health Management Program launched in January of this year.

Year one focuses on managed care plans building a comprehensive population health management strategy, updating their population needs assessments in partnership with our local health jurisdictions and behavioral health partners, streamlining initial Medi-Cal assessments by delegating the Health Information Form or Member Evaluation Tool, also known as the HIF/MET, to providers and focusing on provider driven initial health assessments while eliminating multiple duplicate assessments for our Medi-Cal beneficiaries who said that they were having assessment fatigue in our program.

This eliminated things like the IHEBA/SHA, something that was not seen as evidence based and was long standing in Medi-Cal. So streamlining that member experience and provider experience. Future years will include risk tiering and stratification, as well as additional population focused strategies. DHCS held 26 All Comer Office Hours and public stakeholder engagement technical assistance events through 2022 to inform this work, and we're really excited to see it getting off the ground this year.

In way of providing holistic care, as I mentioned, for high risk populations, DHCS is implementing Enhanced Care Management and community supports. You heard both panelists previously talk about how important these are. CalAIM is really meant to break down the four walls of healthcare and meet people where they are, which can include on the street, in a shelter, in someone's home.

Our approach was built off of whole person care pilots and the health home initiative across the state, and an independent evaluation of the pilots demonstrated that these investments decreased emergency Department visits, inpatient services, connected members with needed care, and reduced overall cost. In 2022, DHCS transitioned the whole person care and health homes populations to ECM and community supports. We went live statewide with adults experiencing homelessness, serious behavioral health conditions, and high utilizers.

In 2023, we implemented enhanced care management for individuals in long term care settings as well as preventing those skilled nursing facility admissions. This just launched. In July, we will be launching populations of focus for children and in 2024 we'll be focused on birth equity and our justice involved populations. Through quarter three of 2022, we had 956 ECM providers across the State of California and provided services to over 88,000 utilizers of Enhanced Care Management.

First time member ECM enrollment has increased since the ECM benefit went live and we know that it will continue to increase as we embed it into our delivery system. Also through quarter three of 2022, we had 1212 community support providers and over 27,000 Members receiving at least one community support service.

At least six community supports are available in each county across the entire State of California and there are 38 counties with at least 10 of the 14 community supports and 13 counties already offering all 14 community supports available through CalAIM. We think this is a great expansion for the first year of launching, but we know that we have a lot of ground to cover. There have been lessons learned from whole person care. This type of transformation takes time.

Many of our pilots needed a year or two to really fine tune their processes, their implementation and their models of care. And so we are committed to working with our partners to make sure that we bring those learnings statewide and that we build that. To recognize that DHCS produced several guidance documents to help ease the transition into CalAIM. We released guidance on billing and invoicing, provider enrollment, coding, guidance, data sharing guidance. We've really tried to provide comprehensive technical assistance for our providers.

This is a huge lift, especially for some of our providers who are non-traditional medical providers, so they are learning Medicaid at the same time and that is a huge lift. We have done hosted spotlight series and public webinars aiming really to review and reinforce our policy guidance. We have identified and amplified best practices and lessons learned for many of our providers, bringing those people on the ground to share their information and learnings with both managed care plans as well as other providers.

We've been responding to emerging questions from the field and providing feedback loops with our providers and as Michelle mentioned, we kicked off a statewide listening tour to go around the state and hear how are things going and where do we need some improvement. Transformation this large needs that type of on the ground listening and we are very committed to that.

Some of the early identified challenges that we have heard from on the ground providers and plans as we've gone around the state and in our provider groups are identifying that there are pretty large workforce shortages. We are hearing that some of the teams are struggling to hire staff to meet the needs across.

We also are hearing, and we know well, based on the various housing and homelessness hearings that have taken place, that there is a lack of affordable housing for the throughput of some of these services. And we're working very closely with our partners to make those connections. Community based organizations are unfamiliar with billing in Medi-Cal, and so we've done extensive technical assistance to help with some of that.

But there is still a scarcity of infrastructure and resources in certain parts of the state where there are additional demand than we are able to serve. And so we are working to build that infrastructure. And I will walk through some of the ways in which we're doing that.

And Ms. Cooper, to make time for the other panelists, if you don't mind accelerating a bit, because we will be able to call on you as questions come later also. So go ahead.

Perfect. So I will walk through some of those pieces. I will also just flag, we have incentive programs. So the CalAIM incentive program was really focused on building up that infrastructure in ECM and community supports. All managed care plans needed to submit a needs assessment. One thing I would point out, which I think is important, we also required all plans to identify populations of disparities, and all of our managed care plans reported disparities of individuals who identified as black members.

Others said that they also saw disparities among Hispanic, Latino, Native American, and mixed race. However, what we're seeing in our early data is that black members have an approximate 7% of Medi-Cal population and, for example, can often show up as black members of 30% to 40% of our homeless population. Early data is showing that 22% of our ECM is being provided to individuals who are black and 33% of our community supports.

So we're really feeling like there has been a focus in regards to closing some of those disparities to ensure people are getting access to some of these services. An additional way that we are getting dollars out to providers to grow that capacity is through PATH. So we have learning collaboratives, we have grant funding, and we have what's called a TA marketplace. Some of our early pieces, we had 237 applications, a total of 559 million in round one. Obviously, we only had around 100 million to grants.

So in January 31, we announced 119 million to 98 organizations. In March, we'll be announcing another 41 grants for an additional $100 million. So really getting dollars to providers. Also give some updates quickly on our dual eligibles-

We are out of time.

Okay. That's fine. We'd be more than happy to answer questions. Sorry. CalAIM is extremely comprehensive. They asked us to give an overview of all the pieces, but happy to answer any questions that you have.

I appreciate it is very comprehensive, but I know my members on the Committee will have lots of questions, and we still have two more panels. And I know there was more you definitely could tell us, and apologies that we have this limited time, but I know I'm expecting that people will ask you questions. All right. We will now move to the next panel, and that is on Enhanced Care Management and community supports. And the folks that are on this panel are basically the-

The Institute or the entities that are implementing delivering the care or being the advocates for those who are delivering the care. So they are basically the ones who are providing the coordination of care for high need populations and the connections to services. As you've already heard, there's now the ability to use medical to Fund some of those services. So let me introduce quickly who's on this panel, and then I will have the first speaker start.

So we have Linnea Koopmans, who's the Chief Executive Officer of local health plans of California. We have Greg Garrett, who's the Chief Operating Officer of the Native American Health center in Oakland. We have Linda Nui, and I hope I pronounced your name correctly, senior policy advocate from the Western center on Law and Poverty. And Kieran Savage Sanghuan, who is the Executive Director of the California Pan Ethnic Health Network. And let us start with Linnea. Go ahead, Linnea.

All right, good morning chair and Committee Members. Linnea Koopman is with the local health plans of California. LHPC represents the 16 local community based medical managed care plans that collectively serve over 70% of medical managed care beneficiaries. Preparing for and implementing Calam over the last year has been a tremendous effort involving multiple partners at a local level.

So while I'll share some of our early experiences, including a successful transition from whole person care and health homes, and steadily growing enrollment into ECM and community supports over the last year, realizing the vision behind Calam will truly be a multiyear effort. Ahead of the calame launch in 2022, the starting point for local plans to develop networks for ECM and community supports was assessing existing relationships and infrastructure.

This required close work with counties that operated whole person care pilots and for plans that participated in the health homes program. It also required engagement with these providers to transition them to CalAIM. Prior to CalAIM, many local plans also funded pilots or grant programs to deliver services that are now community supports, including housing related services. So, they had relationships with these community providers to build from to expand capacity to deliver both ECM and community supports.

Local plans identify which providers are already serving ECM eligible Members and for community supports. Local plans connect with community organizations and providers that deliver community supports like services that have historically provided these services outside of Medikal. State investments, including the Calam Incentive Payment Program and the Housing and Homelessness Incentive program, have also been and will continue to be instrumental in supporting providers to develop the necessary capabilities to contract to provide services to get IPP dollars out into the community.

Local plans have awarded grants to their provider partners to help support staffing costs, data exchange infrastructure and tar training, and with HHIp, the incentive program that is a part of the state's home and community based spending plan. The funding has supported strengthening the relationships, coordination and data sharing between housing providers and plans in order to then engage Members and ECM and community support services. Local plans identify eligible Members through available data and share these eligibility lists with their contracted providers to conduct outreach.

Note that there are limitations to these eligibility lists as many criteria for both ECM and community supports rely on social determinants data, which plans have limited access to. Additionally, outreach engagement takes a significant amount of time and effort, often involving many different outreach attempts to engage Members and services. This is why education to providers about these new services, the eligibility requirements and referral pathways for warm handoffs is key and will likely be the best strategy for Member engagement.

Finally, it's important to acknowledge the realities and challenges with implementing Calen. First, Calen is not immune to the workforce challenges experienced by all other sectors and systems. In many cases, workforce shortages have impacted providers'ability to contract, or if they do contract, it impacts how many beneficiaries they're able to serve. Second, rural areas that have historically had access issues and limited community resources likewise have very few providers or cbos. So service delivery in these areas is challenging and will require creativity and flexibility.

Additionally, although ECM and community supports are two CalAIM initiatives, they include 15 new services in medical managed care, each that require different community resources and physical infrastructure. So, ramping up statewide will take time and will look different based on local factors. In closing, the work to implement these initiatives and services is critically important, and it's also difficult. It involves multiple partners, systems and resources. Local plans are the Caleem implementers in their communities and are committed partners to supporting Calem's success in the years ahead. Thank you.

Thank you very much. Next up is Greg Garrett of the Native American Health center. Out of.

Me.

Thank you. Yes, as noted, I'm Greg Garrett. I'm the Chief Operating Officer here at Native American Health Center, Oakland, California. We at Native American Health center have the mission to serve Native Americans and Alaskan natives, and of our 12,000 Members, about 10% are of that heritage. We have a predominant population of Latinx community Members here in the Fruitville district and that comprises the bulk of our membership, 10% African American, and then a mix of other diverse communities.

At Native American Health center, we consider ourselves an early adopter of care coordination and have really been benefited from being here in Alameda County, which has a very strong integrated network between our healthcare services agency, our local initiative, Alameda alliance for Health, and the Health centers that represent the medical participants in our had. This process that has led up to enhanced care management has really benefited from an evolution of programs here in our county.

We first started nearly 10 years ago with a WHO staff Member on our clinic floor who stands for Warm handoff, and that behavioral health clinician is still to this day on the clinic floor so they can receive warm handoffs from providers who find need for behavioral health services when they are interacting with Members in the exam room. That warm handoff occurs right on the clinic floor and that leads to integrated behavioral health services.

That process then evolved in our county with a program, Dr. Laura Miller's on the line. Dr. Miller created a program called Care Neighborhood and that was formed at our local regional Association, CHCN, with the support of seed funding from our local initiative, Alameda alliance. And thank you to Scott Coffin, CEO there, who understood the benefit of these close care coordination programs, closely knit care coordination programs.

So care neighborhood then evolved, as you heard from other speakers, into health homes pilot and then into the whole person care pilot. So that program became the foundation for the Care coordination in those state DHCS funded programs. Excellent programs, by the way. And as noted by other speakers, the evidence proved and has shown clearly here on our floor that these programs do in fact divert individuals from the emergency room and improve health outcomes. Those programs then rolled into what we now call CALA and ECM.

So we've been very involved in this evolution of care coordination in our county and here within the state. Very proud now that we have gone from two peer coordinators previously throughout the process, to now with past cited funding. So we're very critical. Funding provided through Calais we were able to ramp up, and now we have six coordinators. We've gone from serving just over 60 Members and now we're serving nearly 250 Members.

So calm has tremendously impacted our ability to serve our Members in this critical, and just to give an example of how important this program is, previously we were chasing grant dollars to Fund these services and we were providing unreimbursed, uncompensated care because these SDOH connection programs are critical to our members'well being, to their health and to their outcomes. Now with Calam and through the evolution of health homes and whole person care, we're now able to build a sustainable care coordination system within our agency.

And as we're watching it build within our county and this system is critically important because these are services that unfortunately our providers had to provide. We had doctors, we had nurses, we had medical assistants making linkages to transportation services, to meal programs in complex eligibility and enrollment systems to get into Calfresh, to get into medical, to get into SSDI. Excellent presentation by CHCF in the complex healthcare system that our patients have to navigate.

And that was taking away time from our providers being in the exam room providing the critical clinical services that allows them to provide health benefits to our Members. So we call our care coordinators, force multipliers by our providers being able to provide warm handoffs to these care coordinators. It allows the provider to focus on the excellent clinical care that our providers provide, and it allows care coordinators to provide the very important, critical services to connect our Members to SDOH services.

These services that are provided more upstream prevent the downstream suffering and costs that both the patient and the state budget are having to pay for. So these programs, I could say so much more.

But let me end with just saying that we are also in contract negotiations in San Francisco with San Francisco Health Plan to expand our ECM programs there, and we expect a similar size program to be operating there as we operate in the mission community, Mission District community there, which has very high need for such services. So we're proud and honored to be here speaking to you Members of the Committee. Thank you, Madam Chair, for making this invite for us to be here.

We look forward to sharing our experience and to answering any further questions you may have.

Thank you, Greg. Appreciate that. And we will now hear from Linda Wei, who's the senior policy advocate from Western center on Law and Poverty. Linda, go ahead.

Good morning. Linda Way with Western center on Law and Poverty. Enhanced care management and community supports can and has improved the lives of Medi Cal Members by providing coordinated care that addresses the needs of the whole person wherever they are located. However, our legal aid advocates report challenges accessing both enhanced care management and community supports. They have clients on waitlist with no time frames on when they will move off.

Therefore, it's unsurprising that the number of Members receiving community supports dropped from quarter one to quarter two of last year, instead of increasing due largely to the number of whole person care pilot participants receiving community supports during this time being cut in half. This is reported as a graduation of whole person care participants no longer needing community supports, but we suspect this could be due to long waits that result in participants dropping out or narrow eligibility criteria the plans impose.

In addition, clients report difficulty assessing and being assessed for enhanced care management, which differs from community supports in that it is a benefit, not a plan option for any Member who qualifies plans take referrals for assessments, and clients report no response, even though enhanced care management might be urgently needed. We appreciate it takes time to build provider capacity, but considering significant investments to do just that, how long are Members expected to wait to receive needed services?

Housing support services, which links individuals experiencing homelessness with housing through housing navigation and transition services. Housing deposits and tenancy sustaining services have been shown to improve health outcomes and are particularly important considering the rising homelessness and those experiencing homelessness with a disability the Department has shared. Its goal is to make all community supports a statewide medi Cal benefit, with housing support services being the farthest along.

We recommend requiring the state request federal approval to make housing support services a benefit, with AB 1085 by Assembly Member Maienschein being the legislative vehicle. In addition, we also recommend the Department articulate specific, measurable targets, define a mechanism to hold plans accountable, and publicly report on progress toward those targets. These measures should, at minimum, include providers, specifically trusted community partners who have experience providing services and the number of unique Members receiving enhanced care management and community support. Thank you, thank you.

And now we will go to Kieran Savage San Juan, who's the Executive Director of the California Pan Ethnic Health Network.

Great. Thank you chair and Members Kieran Savage San Juan with the California Pan Ethnic Health Network, or CPEN. So first we were asked about the view on the extent to which principles of equity have been incorporated into implementation. Equity is certainly a guiding principle for Calam. However, without intentionality in every aspect of design and implementation, the impact of Calam will not be equitable. At this point, our biggest concern is the inadequacy of the underlying service network.

While appropriate referrals may be made if the services aren't available or aren't responsive to the unique cultural language and other needs of the Member, implementation will falter. We are enthusiastic supporters of the community health worker benefit, a potential game changer for racial equity and Medi Cal. But community health workers by themselves cannot solve the problem of lack of available resources and services without the right market incentives for ECM and community supports.

To achieve equitable outcomes, there must be a robust and community based service network that requires transparency and a level playing field for smaller racially and ethnically diverse cbos. Currently, community based organizations, that would be ideal. ECM and community support providers are struggling to become providers because of uncertainty. With the plans, Low rates, limits on the number of billable visits, and an unwillingness, in some cases of health plans to negotiate fair contracts.

This initiative is a heavy lift for these cbos, who are now expected to convert their billing structures from a grant based system that includes administrative overhead to a fee for service billing structure that is much more sensitive to market changes.

One community based ECM provider shared that they feel calam would be more successful if community providers were rewarded for improving the health of Members rather than only paid for providing services when Members are experiencing their highest needs and then losing the ability to provide services to that Member when their health improves to the point that they no longer qualify for ECM but would still benefit from support.

The other question we were asked to address was the risk stratification process and the concern around potential bias in this algorithm and the data that is being collected to try to avoid bias. So we would say in General, it's too early to know what the outcome of the risk stratification processes will be or whether there are disparities in enrollment. So it will be important for the Legislature to continue to monitor this issue.

Some of the data which Linda alluded to really pertains to Members who are transitioning from whole person care and health homes, and so they had already been identified and connected with care management services.

1 second, Karen, I don't know if it's your sound or here it's hers. Your volume just went down. I don't know if there was any adjustment you made on your end that we know.

How's it sound now?

Much better. Much better. Okay, keep going.

Okay, I'll just speak up.

Great.

So I'd say the racial breakdown of the ECM population is similar to that of whole person care participants, with the exception that there's a higher enrollment of Latino Members in ECM. Some ECM providers who serve communities of color and were previously health homes or whole person care providers, have noticed that their outreach lists for new enrollment are smaller compared to health homes and whole person care, which raises concerns that some Members are being missed because of this program.

Transition and community based providers have observed limited outreach to Members related to community supports, and you do see in the DHCS's data that the number of Members receiving community supports at this time is quite Low. We do appreciate that DHCs is prioritizing addressing bias in the risk stratification design process and has determined that risk tiers must be based not only on medical or behavioral health risk, but also on social risk and most importantly, must consider underutilization of services.

Measuring utilization and underutilization will help to reverse bias in risk stratification. This is because the evidence shows that black patients and LGBT, two patients in particular, consistently generate fewer costs than white patients at the same level of health. The measures DHCF is proposing will help us understand the extent to which different populations are utilizing or underutilizing services and the extent to which the identification of Members for ECM is successful or is generating bias.

We have just a couple of recommendations to strengthen it, which would be requiring.

A public need to wrap up.

Okay. Requiring a public dashboard, measuring patient activation and measuring community engagement. Thank you so much.

Great. All right, we are now going to our final panel, and the final panel is on 1 second, I'm pulling up my on the behavioral health reforms and the California Behavioral health community based continuum demonstration, which is also another component of Cal Aim. So the panel will provide us perspectives on the implementation of how the behavioral health services, that's mental health and substance use disorder treatments, are going to be delivered to Medi Cal beneficiaries by county behavioral health departments.

And for our panel now we have Michelle Cabrera, who is the Executive Director of the County Behavioral Health Directors Association, Dr. Leandra Clark Harvey, who's the Chief Executive Officer of the California Council of Community Behavioral Health Agencies, and Kim Lewis, who's the managing attorney of the National Health Law program. So, Michelle, would you like to start?

Good morning, Madam Chairman, Members. My name is Michelle Cabrera and I'm the Executive Director of the County Behavioral Health Directors Association of. California. County behavioral health agencies are responsible for the delivery of specialty care for individuals with more significant mental health treatment needs, as well as those who require substance use treatments. Under Medi Cal as plans, our county behavioral health agencies are required to meet the managed care rules, including network adequacy, timely access and quality standards, and to comply with parity laws.

The CalAIM Vision for Behavioral Health was largely developed pre 2020 at a time when we were trying to solve for some very specific challenges that were holding us back. First, because of our financing mechanism, where counties put up county funding to draw down federal match for Medicare health services through what's called a certified public expenditure. Counties were then, and are still today, required to document our services to the minute. This requirement has been corrosive to our system from a workforce perspective.

It shifted our focus away from people and onto paperwork. And while we have most of the same requirements as managed care plans, because of this structure, we've had no ability to generate the savings that could be reinvested into our system. So while our basic cost of doing business has been covered, our ability to grow has been stunted.

Finally, our health plans and providers have been subjected to multiyear audits whereby we carry risk to the tune of hundreds of millions of dollars each year as payments are either reconciled over or under cost. In fact, we are still in the process of settling claims with the state that go back as far as 10 years. For these reasons, and many more, our counties have embarked on a multiyear effort to overhaul how we get funded.

Phase one of this effort is to make the move from cost based reimbursement to fee for service. The state's been working with us to figure out how to convert the information we have on costs into a fully loaded, plan based fee for service rate that accounts for covering our costs, along with some adjustments for inflation, labor market and other factors.

We have to commend the state, the team at DHCs, specifically for working collaboratively with us to ensure that we account for as much as we can in building out a whole new payment system for the six to 7 billion plus of medi Cal specialty behavioral health services that we deliver. And while the state has worked very closely and collaboratively with us, this timeline is aggressive. To date, we've received seven sets of rates, with the majority of those coming to counties as recently as last week.

We're still awaiting four sets of separate rates. Once we get these rates, counties need to model them to understand the potential impact, and we won't have a complete picture until all of the rates have been released. The January budget proposes $375,000,000 to address this transition from cpes to igts. Without this funding, our payment reform goals would not be possible. In any event, the aggressive timeline will make it a real challenge for our counties and especially our providers, who will have even less time to transition.

Some counties have anticipated the challenges and are looking to build in additional incentives to help our providers weather the transition. We've been working alongside DHCs and our joint powers Authority to provide training and technical assistance in modernizing our payments. We hope to pave the way for future fewer documentation burdens and financial risk. In addition, our payment reform to payment reform counties have been preparing to set up a statewide network of 24/7 mobile crisis services under medical.

We have until the end of this calendar year to set up mobile crisis capacity, and we're extremely grateful to the state for its investment in infrastructure funding to help us purchase vehicles and equipment related to these services. While this new Medi Cal benefit is exciting and builds upon decades worth of experience in some regions, other parts of the state, particularly those in rural California, have not until now had the mandate or the funding to set up mobile crisis services.

Workforce challenges will make hiring professionals skilled in field based crisis to scale. Extremely challenging. And although we've had emergency responses for fire, public safety and medical services as broad public benefits, we will still lack reimbursement for the 70% of Californians with some form of private insurance, which makes sustainability and providing services to the community more challenging.

Finally, we're working closely with the state to make significant improvements in access to quality outpatient services through the CalBHCBC demonstration, which will allow county behavioral health agencies to pay for services like community health workers, to do outreach and engagement as well as housing, and to be reimbursed for short term residential and inpatient stays that today are excluded from Medicaid because of the size of the facility.

I want to point out that we believe that the potential savings generated through the IMD waiver could be significantly lower than the state's estimates. As we understand that the state estimated their 3 billion plus number on savings we would accrue if all types of inpatient stays, rather than the eligible subset were new funding for us.

As such, we've asked the state to work with us to ensure that counties that opt into the waiver have enough savings in new federal reimbursement to finance the various required new benefits that would come under the Cal BHCBC.

And if you could wrap up?

Absolutely. For counties, the promise of Cal aim is that by expanding medical reimbursement to touch more of what we already do, a system that for decades has touched schools, Carceral Systems, housing and social services, that our Medicaid agency will both support growth through new opportunities for federal match, while also gaining better insight into the strengths of our system and changing our relationship with managed care plans, our providers, and ultimately our beneficiaries. Thank you.

Thank you. All right. Now we'll hear from Dr. Lee Andra Clark Harvey from the California Council of Community Behavioral Health agencies.

Thank you. CBHA's Members are mental health and substance use disorder clinics and businesses who collectively serve more than 1 million clients, including the Native American Health center, who you heard from during panel one. Cal Am symbolizes an innovative approach and a huge opportunity to address the multitude of disparities that exist for clients in our state. That's why it's imperative that we, counties, providers and the Administration works together to get it right.

Despite its promise, I've been asked to discuss mechanics that need to be fine tuned, including payment reform. So in theory, providers should benefit the proposed move from current procedural terminology CPT codes to intergovernmental transfers IGT payments. This reform should eliminate the burden on counties and providers regarding the cost settlement process, which can often take, as my colleague Michelle said, multiple years to reconcile. But innovation is only as good as the funding specifics that bolster it.

It is very difficult to discern specific benefits from payment reform given that providers have not yet received rates for services. We are seeing wide variation across the state regarding budget information requested from the counties and DHCs, the timeline for a response, and how this information will be utilized to develop provider rates for 202324. Providers direly need to understand the billing and transactional changes associated with the move to the CPT code system and also linked to payment reform is providing care in community based settings.

This is not a new concept for CBOS wraparound programs, mental health service, MHSA, full service partnerships, et cetera. Many clients are just not able to receive services in a traditional clinic based system. That is why it's essential that the reimbursement rates fully cover staff's travel time and transportation to provide care in the community. Saying that travel is already baked into overall rates set for all providers just isn't adequate because provider services are diverse.

For example, we have one provider who provides 90% of their services in the field at schools, services provided in the community for those who are unhoused, et cetera. We have another provider who provides services to residents of Catalina Island and travels 3 hours per visit round trip as it relates to the California Behavioral health community based continuum. Providers are also concerned about the sustainability of funding to help counties and providers implement and train staff to engage in evidence based practices.

And in order to avoid IMD utilization, there has to be adequate resources available along other parts of the continuum of care. I'd be remiss if I didn't close by mentioning workforce challenges. Workers need increased incentives for continued work in the public behavioral health system, especially when Amazon and FedEx is paying more. And at a time like this, we can't afford to burn out our workforce due to administrative burden. Hiring teams of individuals to manage varying paperwork requirements across counties just has to stop.

DHCS has attempted to solve this by convening a diverse group of stakeholders to advise on trimming down documentation requirements. But without required standardization across counties, we're in the same spot as not all counties are willing to change their processes. And in fact, out of 70 community based organizations we surveyed, only one said that they were receiving relief as a result of the DHCs work groups on documentation. So there are lots of well intended recommendations, but if they don't have teeth, they just won't work.

Last crisis care cbos have long led the way with call centers and are continuing to do so with 988 and are effectively providing mobile crisis services in many different counties across the state. The ability to carry the service system must be recognized and continue to be funded. Thank you for the opportunity to reflect the policy priorities of behavioral health providers that CBHA represents.

Thank you, Dr. Clark Harvey, for those comments. And let us now move to Kim Lewis, who's the managing attorney at the National Health Law program.

Good morning, chair Skinner, Members of the Committee. I'm Kim Lewis, managing attorney of the National Health Law program. So I've been asked to answer a number of questions and I'll try to get to a few of those. Particularly what are the barriers that exist currently to access necessary behavioral health services, and how is caling the behavioral health implementation addressing that impact? So the barriers are obviously, honestly, the medical delivery system structure itself. Consumers have no idea who's responsible for behavioral health services.

When you add to that the complexity of the medical services that are covered, different services for children and youth under 21, variation between counties as to what's covered for adults, it becomes even more challenging for beneficiaries with disabilities and families to know what's covered and how to get it. When beneficiaries are involved in multiple systems like child welfare, justice systems, Regional Centers or others, the confusion about who's responsible and where to seek care becomes even more daunting.

Even now, after Calam has begun to roll out, people on medical still do not understand Calim and the right to obtain medical services or where how to obtain them. Calm changes to the behavior system were specifically intended to address these barriers, and three specific policies that have been implemented are particularly critical for Medicare beneficiaries needing mental health services. First is improving access or expanding access to the front door of the county delivery system to obtain specialty mental health services or substance use disorder services.

Second would be the no wrong door policy allowing beneficiaries to seek care from both the county behavioral health systems and their health plan so beneficiaries can receive non specialty mental health via a medical managed care plan or fee for service provider and specialty mental health via a mental health plan concurrently, when all the services are clinically appropriate and the treatment is coordinated between those delivery systems.

And then third, finally, beginning in January 2023, the implementation of a statewide and unified standardized screening tool, one for adults and one for children under 21, that all delivery systems have to utilize to determine the most appropriate medical mental health delivery system referral for beneficiaries who aren't receiving mental health services when they contact their health plan or the managed care plan, their mental health plan. At the bottom line, we don't yet know how are these policies working to improve access?

It's still too soon, yet we know beneficiaries remain confused and more needs to be done on that front. So what additional improvements should be made to the behavioral system to improve access? Well managed care plans and county menahau plans need to collect and report data to track referrals between delivery systems so we can see what's happening with beneficiaries across the continuum and know that they're actually getting the care they're seeking.

And the Department and the counties need to track how the new specialty mental health access criteria for youth, particularly those involved in child welfare or juvenile justice or experiencing homelessness, are better addressing the needs of those populations and the goals of caling when California needs to better integrate all medical and behavioral health delivery systems, both administratively as well as at the service delivery level. As we know, holistic care across the spectrum is most effective and better.

More timely, user friendly data is also needed to determine what's happening with access. We still have no 2022 mental health data available even on the state portal, so we don't really know what is happening and how access has changed. I can speak to specifically the issues around avoiding unnecessary utilization of institutes for mental disease, which I was also asked to talk about if you'd like me to. Or I can wait and answer those later.

You have about 45 seconds left, so if you okay, great.

I'll be quick. So for children and youth, California needs to refocus its efforts on the availability of intensive home and community based services, including intensive care coordination, intensive home based services, mobile crisis services. These are critical to the success of high needs youth, in particular those involved in multiple child serving systems.

We also need therapeutic foster care to get off the ground as the state and counties have struggled to get those treatment homes stood up and the services are intended to provide and avoid institutional residential treatment facility alternatives. And for adults, we need to add those evidence based practices, assertive community treatment, supported employment, peer support services, permanent supportive housing, mobile crisis services and finally, intensive case management for adults who don't get act.

Those are critical additional services that some of which the state has invested in and is planning to add to the Medi Cal services. But they need to be available statewide and not just the county option. Thank you.

Thank you very much. All right, so Members, we can now move to your questions, and as I indicated, what I'd like to start out with is two from you and I will make the list and then we will come back to people. I am going to start, followed by my Vice Chair, Senator Niello, and then Senator Roth, Senator Laird, let me see who. Okay. Benjabar. Great. Bayardo. Okay, Mr. Dahle. All right. And we can add other people as time. Okay. Androzo. Okay. As time goes on.

All right. So I really appreciate all of the panelists. This is clearly very complex. I mean, we've been learning about the difficulties of payment issues. We've been learning about the breadth of services that are provided, the difficulty of perhaps not enough providers, maybe workforce issues, too, trying to expand other community based organizations to be part of this network. I mean, it's a lot, but I want to go back to Malora Simon, who was our first presenter. And Malora, in your.

If you are still available, I hope you are. One of your slides that you showed had California in the bottom quartile. It showed us as having the largest number of Americans under our Medi Cal program and so dependent on this program. But we were in the bottom quartile of. I'm not sure what was the exact metric that you described. Just quickly tell me and then I'll ask you the question that metric was.

So it's a survey that looks at consumer experiences of managed care. And there are two measures. One is about getting needed care, and the other is about timely access.

Right. That's what I thought, but I didn't want to say it and be wrong. So it was the access and timely care. Okay. So what I'd like to hear is what are the one or two things that California would need to do in order to change that to increase the access and the timeliness?

That's a great question and a complicated question, and I wish that my colleagues who focus more on access were here. I think network adequacy is a term that's kind of thrown around, and it's about whether managed care plans have enough providers with open panels so that people can get in. And I think that provider participation in Medi Cal is probably lower than it needs to be and why that's a real opportunity.

Any particular reason why?

Probably has something to do with rates and the gap between Medi Cal rates and Medicare or commercial rates.

Okay, thank you. Appreciate it. And then my next question is for JC. So it's similar along these lines is you talked about the evidence based results. How will our service deliverers achieve those results when the recipients are experiencing significant delays before care and sometimes not access to care?

Happy to respond to that question. So DHCS has been very focused on our network adequacy assessments, both of our medi Cal managed care plans and our county behavioral health partners. We have been incrementally increasing the reporting around this, and even one of the measures that we are rolling out to our managed care plans focuses on how they are increasing utilization to primary care and closing the gap of non utilizers, making sure that people have easier access.

We've also, through the implementation of the community health workers that was mentioned earlier, we really see that as an additional access point. Not everyone needs to see a physician, nurse practitioner or physician assistant. And so we're really thinking about that as a great touch point for education engagement after a new diagnosis, making sure they understand how to navigate our delivery system. It can be quite complex.

And so we're really thinking that will be a very culturally appropriate way of educating people in their language, in their home and in their communities, and really connecting that trust and engagement with our Members. So we're really excited about that new benefit that just rolled out. So we're just starting to see that increase across the State of California.

So both our oversight and monitoring of network adequacy, we have done some rate increases, as well as the community health worker benefit really being the ways that we are focusing. We're also implementing an alternative payment methodology for our FQHC partners so that they can also have more flexibility in their model of care and look forward to seeing these reforms kind of come to fruition.

I appreciate that. And I think for many of us, obviously your Department, you, the providers, are all steeped in the terminology that you use such things as network adequacy and all. And I think for most of us, while obviously the terminology is helpful, we want to get it right. We also would like to have that terminology translated into what does this mean in terms of people getting care?

So if the future, those who answer any of our questions could be more specific in terms of that kind of translation for us, I think it would be appreciated, rather. All right, so let me move now to Senator Niello.

Thank you, Madam Chair. My two points, I think, get to what you just concluded with. My first will be a point of personal privilege to sound like a broken record. This program, it's new to me since I'm returning from just a brief 12 year absence, and I think this has promised to have a great effect, and that's a good thing.

My concern is, number one, in the area of homelessness, we continue to be guided exclusively by the policy of housing first, and that can show success, as in the first handout. The Rosalind story started with getting housing first as a breakthrough, and there was an article in the Wall Street Journal recently about a housing first approach that showed promising results for some veteran groups outside of the State of California.

The problem is, if all we can use to guide our funding decisions is housing first, we eliminate some programs that do show great success, one of which is right here in Sacramento, the St. John's program, which, because it's a residential program of mothers and children, has to require sobriety. And for that reason, they receive absolutely no public funding whatsoever. They receive private funding, and that's what funds what they do. I contribute to them.

I'd encourage everybody within the sound of my voice to contribute to them, but it is a real shame that they are totally uneligible for public funding. So I mentioned this at our homeless hearing, and I'll mention it again. I think it's time for us to reassess that program, adopted in 2016, since when we have experienced the explosion in homelessness in our state. My second question does get at the issue of results.

We want these programs to result in better health outcomes for individuals, and I'm sure we'll do a great job of measuring what everybody does, and I hope we do a great job of measuring what is actually accomplished.

But given the nature of the program and the large number of entities and agencies that are involved that haven't necessarily been coordinating in the past, if the outcomes aren't there, and so many different agencies have a hand on a particular outcome, if it doesn't work, if the outcomes don't work, who's responsible for that? To put it more crudely, who do we know in the spectrum of services to blame for the lack of outcomes? That's really my question.

How do we know if the outcomes aren't there, who in the broad spectrum of participants might be responsible for that particular failure?

So, JC Cooper, happy to answer the question. If I can ask one clarifying question. When you're speaking of outcomes, are you talking about all of the various outcomes and components of Calais? Broadly, I just want to make sure I answer your question specifically.

Yes, because it is such a large and comprehensive program, hopefully we'll assess outcomes. How do we assess who needs to do a better job to get better outcomes?

Sure. So happy to answer that question. I think that ultimately, the Department of Healthcare Services is leaving the implementation of Catlane. While Medi Cal is large and complex and does cross over multiple systems, including sister agencies and delivery systems, ultimately we are working with our various partners to implement that. That being said, there are large components being implemented by our Medi Cal managed care plans and our county behavioral health plans as well.

And so the Department works very closely with our managed care plans in regards to meeting the expectations that have been outlined by the Department, including not just making sure that people are getting access to services and utilizing those services and the right people are being connected, but also the health outcome improvement. Are we seeing the intended outcome? And so we will have dashboards. We've started posting some.

We will also be bringing in an independent evaluator to make sure that we are having that third party also evaluate the successes of the program, and that would be the same on our county behavioral health side. There have been significant changes for them to implement and so we will be holding them accountable through data that we'll be posting, not just utilization again, but outcomes in regards to connecting people with services and ensuring that the intended policies are being implemented to Fidelity.

And so we are looking forward to getting those dashboards public. It's just our first year in and we have a data lag is a common thing. I know people want to see data fast, but we do need to make sure it's complete and that it's quality. And so we are working on getting those dashboards up. But ultimately, DHCs, our other sister departments and our managed care plans and county partners are ultimately the individuals responsible for implementing Calam components and seeing it come to fruition.

Did anyone else want to address Senator Neelo's question?

Go ahead.

I appreciate the answer.

Okay, excellent. So now we will go to Senator Roth.

Thank you, Madam Chair and to the panelists. Thank you for working on this rather complicated CalAIM issue. I have two questions primarily for, I guess, the state and others can chime in.

Given the realignment healthcare funding disparity among counties in the state, and given the statewide shortage of mental health providers at all levels, particularly in the inland parts of the state, and the shortage of mental health treatment facilities, particularly acute care beds, are you concerned about our ability to meet the CalAIM promise in the behavioral health area? Two, if so, what specifically are we doing about the acute care and behavioral health workforce shortage?

Maybe I'll start. Michelle Baass, DHCS. And if Jacey wants to add anything with regard to kind of the realignment funding with the behavioral health payment reform, really, that we see as opportunity to provide counties with more flexibility in how to use their dollars. And I think that is kind of a path forward to address some of the disparities that we've talked about in the past on realignment.

And with regard to the acute settings and kind of just the brick-and-mortar capacity, we have the Behavioral Health Continuum Infrastructure program. About $1.0 billion have been awarded, adding about 200,000 treatment slots, about 1700 beds. So really building out the capacity that we know is needed. And then just touching on what was already raised with regard to our community health worker benefit, recognizing that we do need to build out the pipeline of clinical personnel and professionals.

But we have community health workers, the peer support benefit, and then Doula, which is not necessarily a behavioral health benefit. But really building out our extenders, other workforce that we think can help address the workforce needs that we have out there to serve our members.

Senator Roth, if I may. Michelle Cabrera with the County Behavioral Health Directors Association. We just last week published an analysis commissioned with University of California, San Francisco, a health force center that documents the significant shortages that we have in the public safety net for behavioral health services. This cuts across licensed and certified Clinicians, as well as our substance use disorder counselors.

And as you note, the Central Valley and the Inland Empire face the most significant workforce shortages. And I would argue that these workforce shortages are a critical threat not only to CalAIM's initiatives, but to the overall safety net services. So one of the things that we've been lifting up is the importance of the state not delaying the investment in education and training for behavioral health workforce as proposed in the January budget.

And really we need to not only sort of fast track those things, but expand on those efforts. And to your point, the recipe for solving our workforce crisis is really twofold. It's expanding education and training, but also increasing pay. Dr. Clark Harvey mentioned earlier, and it's very true, we are losing our paraprofessionals in the field to the gig economy and fast food at an alarming rate.

And we're hopeful that payment reform will help us to, along with CalAIM initiatives, squeeze more out of the existing streams of revenue that our system receives. But it certainly is trying to maximize what we already have, not adjusting for increased demand necessarily.

Thank you. I'd like to, from the Administration, see a set of goals and objectives and plan of action to address specific workforce shortages in areas of the state. And that will give us something to shoot at in terms of the budget. And just a point of clarification from Ms. Baass. Are you saying that the behavioral health Infrastructure program includes funding for acute care psychiatric bed expansion in the state? I was not aware of that.

Yes, it does. In the previous rounds, those were eligible funding types or facility types. Yes.

Separate and apart from this hearing, can you provide me with the number of acute care psychiatric beds that were added as a result of the behavioral health infrastructure funding program? That would be helpful, as opposed to community and residential treatment slots. Thank you very much, Madam Chair.

Great. Thank you, Senator Roth. So now we'll go to Senator Laird.

Thank you very much, Madam Chair. When we had the homeless hearing, Dr. Galley said that this was the one program that would bring new resources to the table for services to the unhoused. And so I'm interested, and it came up through the hearing with Michelle Baass talking about pushing down the walls of the program to overlap with other programs.

And I think the Western Center and even the behavioral health director inferred this. So my question, and I guess I'll start with Michelle Baass, is how does this bring more resources to the table and how do the people that might get the resources know about it?

So I will start and then turn it over to Jacey, but it is bringing additional federal dollars and state general fund with regard to our community supports, the community supports related to housing and homeless services. Jacey, do you want to maybe take it with more detail?

Yeah.

And the more detail might be what community supports are that it goes to.

Sure. Yes. Happy to provide that information. So, specifically focusing on housing and homelessness, we're doing two things. We have both an infusion of one time dollars and then ongoing. And I think the ongoing part is really important. So I'll focus on both for you really quick.

So when it comes to the one time dollars, we are infusing significant dollars to build up the infrastructure of these providers that can do housing navigation services, housing transition services, deposits, recuperative care. For example, recuperative care is when someone experiencing homelessness is languishing in an inpatient bed, oftentimes for a very significant period of time, and the hospital team doesn't want to discharge them to the street, they'll languish there.

Recuperative care allows someone experiencing homelessness to be discharged to a medical respite or recuperative care bed or to a short term post-hospitalization and eventually get connected to those housing transition services. We're building for the first time a full continuum of housing services and supports.

And before then, you go to the ongoing money. Let me ask about that, because you describe the services, but you didn't describe who the money would go to to deliver the services. And for example, there's a nonprofit homeless program in my hometown that does exactly what you're saying. They provide rehab beds for people coming out of the hospital. Would they be eligible for this money under this, go directly to them?

Yes. So we have been releasing what we call path dollars. It goes to community-based organizations, nonprofit, public hospitals, county agencies, tribal entities. And we are doing the grants directly from the Department to those community-based organizations. It is competitive. For example, in January, of our 119,000,000 that went out, 78 of the 98 awards were specifically for housing and homelessness providers, exact providers like you are describing, to build up their infrastructure across the state.

This is brand new. We have to build this infrastructure. Or there's great providers like you just mentioned doing this in the community, identifying them and connecting them with grants to be able to scale up. For example, we did fund a pretty significant number of new kind of recuperative care beds, the ones kind of similar to what you're referring to, in this round. So we have another round of funding coming up soon.

Round two will be announced, and so individuals will be able to get those infrastructure dollars in order to scale up and meet the need for these services. So we'll continue to announce those and we'll make sure people are tracking what those are. We also are providing a lot of technical assistance. So we have what's called the TA Marketplace. So maybe that provider isn't as used to billing medical services.

And we are paying from the state for TA vendors to be available across the entire State of California. We did a statewide procurement. We have different vendors in different parts of the state, because it's large, to provide technical assistance for the providers. Like you were saying.

I know other Senators want to ask questions, so let me just ask a follow up question and try to round this out.

Senator Laird, we did ask for two questions only for each Member at this point.

I know I asked one and I'm trying to get a follow up answer because it's basically, you said that this is competitive and yet it probably goes on everywhere and there's a technical assistance place. But how do people really know, how do they know to be able to apply for this?

So we are trying to communicate that across the entire State of California. We have deployed what we're calling kind of various collaborative planning group hubs across each county. We have announced those. They're on our website, and that's really to drive people to being able to have a local source to get information. The other place, I would say, is our Medi-Cal Managed Care Plan. Medi-Cal Managed Care Plan should be doing a full network assessment.

It was their responsibility to do a gap assessment, identify providers in their counties. They can also reach out to their local Medi-Cal Managed Care Plan. That plan can guide them to the various technical assistance links information available. Those would be the best points to get people directed.

I will follow up with you offline. Thank you very much for the response.

Thank you, Senator. Go ahead.

Sorry. May I also respond? Yeah. Linnea Koopmans with LHPC. And so I think just elaborating a bit on the director's remarks just now about the funds that are flowing to manage care plans. Just wanted to flag that the CalAIM Incentive Payment Program and the Housing and Homelessness Incentive Payment Program are two additional funding sources that are flowing through plans into their local communities. So in addition to the past dollars that DHCS spoke about, these dollars are going out by plans largely through competitive grant application processes.

But they're reaching out locally to their provider community and housing providers as well to ensure that there's awareness so that those dollars then can support the capacity and infrastructure development that's needed to occur to expand these services and really scale them to serve the number of members who need them.

Great. Thank you. If there's any other panelists who wanted to answer Senator Laird's question, please identify yourself and you may.

Ms. Nguy with Western Center on Law and Poverty. If I just might add, in addition to, as mentioned by the local health plans, there are these incentive plans we have been hearing from, particularly around the housing support services--these trusted partners that work directly with individuals experiencing homelessness by providing outreach on the streets--that they have found that the administrative rate of providing these services, that their costs have exceeded the cost that they are being provided.

And so as a community support, I think that that's one of the challenges because it has to be cost-neutral. And so moving toward a Medi-Cal benefit is critical in actually being able to ramp up these services and build out the provider network. And so that is something that we would like to see is making, moving toward a benefit for particularly the housing support services.

This is Le Ondra Clark Harvey from CCCBHA. I would completely agree with Ms. Nguy's comments and also add that it's so important when providing these grants and services that we think about integration. Right. So not just housing and not just going for folks that are providing housing services, but how they work with other community-based organizations that are really speaking to the whole person and all of the various needs.

Again, CalAIM is really about integrating care and providers. So even in opportunities for housing services, we have to look at how that works with other parts of the sector so that it's truly efficient and good for those that are in need of the services.

All right. Thank you for those additional answers. And please, as we keep going, if other panelists have, want to address the question that any of our Senators are asking, please, I will call on you. So, Senator Menjivar.

Thank you, Madam Chair. My first question is similar to the Senator to my left here, and it's directed to Linnea. And I know we are documenting outreach and engagement in temps and modalities. We have that data. I just want to know if you go a little bit more into what are the strategies we're employing to get to identifying members who will benefit from support services and the enhanced care management. That's my first question.

Thank you for the question, Senator. So the outreach and engagement piece of this is both really important and also very challenging. I know one of the things that my members are hearing from their providers is that it often takes many attempts and ongoing engagement to get members into care and enrolled in ECM or community supports. But in terms of strategies to do that, I think there's a few different mechanisms. And I want to elaborate on a couple of things I touched on in my testimony.

And so I think first is that plans are proactively trying to identify members who may be eligible for these services. And so what they do then is use available data and then share those lists with their contracted providers so they can make outreach, whether that's in-person, telephonically, or in-care settings, actually in receiving another service.

I would say the limitations to those eligibility lists are that because the criteria to qualify for enhanced care management or community supports is largely reliant on social factors, whether you are unhoused or other kind of social drivers of health, we don't always have that data. It's improving, but it will take time.

So, for example, plans are just starting to get housing data through their local housing management information systems, and that's being in large part supported by the Housing and Homelessness Incentive Program dollars to help make those connections. So I think that's great progress. But again, just wanted to mention sort of the limitations to the eligibility lists that are given to providers.

So I think that's why over time, the education and outreach to providers, delivering care to our members, PCPs and others, about the fact that these new services and benefits exist, who's eligible for them, and then the referral pathways is going to be one of the better ways to engage with members who are receiving care and getting a referral and a warm handoff from their provider. So it's kind of a multi-factored kind of approach to reaching these members and getting them engaged in care.

Thank you. My second question is for Michelle Cabrera. We talk about these support services and I'm a huge fan of what I call holistic care, but we call whole person care approach. And I'm wondering--sorry, that's another question. Two hundred questions and I had to dwindle down. Okay, so the question I want to choose is still to Michelle.

I wanted to talk a little bit more about this mobile crisis infrastructure into the continuum of care-based care. And I know, I recognize the workforce shortage here. But I'm wondering if you could talk a little bit more about--we've invested in a lot in the two years and how are the counties integrating the mobile crisis infrastructure into this continuum of care?

That's a wonderful question, Senator. So as I mentioned in my testimony, we have in some communities decades worth of experience with mobile crisis services in the county safety net. And oftentimes, because these services have not been fully reimbursed, we've really dedicated those mobile crisis services to peak demand hours.

So they're often not available 24/7. And it was really the federal government that offered mobile crisis services through Medicaid, but they attached quite a few strings to the benefit. One of them is that services need to be provided 24/7. So the state, with a lot of foresight, proposed the first initial rounds of the infrastructure funding under the B chip for mobile crisis infrastructure.

And I'll just say we are trying to piggyback and leverage as much of our existing county behavioral health crisis infrastructure to support this. But in some places, it's going to take a lot more time to build out that capacity. For example, I think that the federal structure as well as the benefit here doesn't acknowledge enough the role of dispatch in standing up mobile crisis services.

So oftentimes the goal with mobile crisis dispatch is not just to press a button and send a team out, but to really evaluate what's going on over the phone and see if you can stabilize someone and triage those services in real time right from the phone. When mobile crisis services are necessary, then you need a team that's going to meet the requirements laid out in federal and state law, and there are a lot of strings attached there.

We've flagged that there are significant new requirements attached to the statewide benefit. So that's going to require us to staff to a certain level and to document quite a bit through our services. But the key pieces of sort of how we're leveraging what we have, we got that initial investment from the state.

We now have the new criteria required for Medi-Cal, and as I mentioned, the Medi-Cal funding is only going to cover a third of the state's population. Seventy percent of the state will still be wanting those mobile crisis services. And we frankly have not had good success with trying to get private insurers to reimburse us for those services.

Senator, if I may, I'm so glad you asked that question as well. And Michelle is right. There are limited resources. And so considering that, I would look even within your own district, we have sick and more who I know you've met with recently, who have received funding for mobile crisis, who are doing a really amazing job.

We also have the 98 call centers that provide 24/7 coverage, and the goal is really to try to link those if possible, because as Michelle said, we want a seamless system. It does take time and it takes partnership with counties and providers, and there are models out there that are already working. So I would suggest really looking at how we can build off of those.

Senator, this is Kim Lewis from the National Health Law Program. I wanted to add to the conversation about crisis services. I think it's very important to understand that crisis services, including mobile crisis services, has always been a requirement under EPST, which is the Federal Entitlement for Children under age 21.

And many states provide crisis services, including mobile crisis services, as medically necessary to correct or ameliorate their just mental health disability, which has again been clear from the federal government as a requirement. It's not new and it's not impacted by the most recent federal law that has expanded the qualifying mobile crisis benefit with an enhanced match. And I think has been always a shortcoming.

I think in our state is the availability of crisis and mobile crisis services, particularly for children, and that this really needs to be a benefit that's built into the fabric of the mental health system in a way that when children and adults really, when we add the benefit for adults as well, are getting these services, these mental health services in the community, they need to be thinking about a crisis plan.

And crisis services as part of that continuum, as part of that need, as crisis are not planned for and they arise when you least expect it. And so you need to have a plan in place, and many providers do as part of that sort of wraparound approach to ensure that there is, on paper and in practice, a way to get help when a crisis arises, who to call, what's going to happen and what the plan is.

It's not necessarily calling a hotline or strangers to come out who have no idea what the needs of that particular family are. So I think it's really important that we build in a model that is really going to be effective for this and to remind all of us that this is a benefit that is a part of the Medicaid entitlement. Thanks.

All right, I have three Senators on the list: Senator Dahle, Senator Durazo, and Senator Min. And I will need to go to public comment pretty quickly thereafter because we do have to stop by noon. So let me go to Senator Dahle.

Thank you, Madam Chair. Thank you for the presentations. I will be very precise in my question. First, I want to preface that with what I'm hearing from counties. We had the hearing before. We heard about the cost of housing, which we don't talk about other than giving aid to rent and those things. We had the plans in. We're losing hospitals in California due to reimbursement rates. That's been an issue. And also we talked about the addiction issues, which Senator Niello brought up.

So with that, this is the most broad plan I've ever seen. I mean, this is very complicated. We've heard that today. So my question is, I have the slide up, the second slide, which was provided by the second presenter, or maybe the first, with who does what. And so my question is, where as Senators are we able to go on this dashboard? I heard the word dashboard.

Who's monitoring the dashboard and who will be putting up places where we can go to ask the question like, what are the rates for the providers? What is the county going to do? What is the nonprofit going to do? Who's going to manage that dashboard? That's the I think question for me. I want to be able to go in and actually dive in a little deeper on who's doing what and who's going to be held accountable for the results.

Hi, this is Jacey Cooper from the Department of Healthcare Services. We'd be more than happy to provide you a cheat sheet, for lack of a better description, of the various currently posted information and data pieces so you can get that information and then monitor it. And then once the larger dashboard is released, we'll also make sure that you are aware of that dashboard.

Once we get through the data lag, we are hoping we can get that information flowing so that you can be looking for those improvements and outcomes. And so we're more than happy to offline and get you that cheat sheet just so you have the information.

Will the providers have the ability to say, be able to comment on that dashboard like, we haven't been reimbursed for six months or eight months so that we as legislators can figure out how we can, through the budget process, address some of those issues?

You probably wouldn't see something like that in a dashboard because it's really usually focused on an outcome goal and then how that's being measured and the outcome results of that. We can take it back in regards to how we clearly articulate various challenges that we're hearing and how we, or the managed care plans or county entities, of course, who oversee these initiatives are addressing those items. We do have very extensive advisory committees on CalAIM.

So we have behavioral health specific advisory committees that includes hospitals, providers on the ground providing feedback loops to us. So we vet everything on CalAIM through these various advisory committees. But I don't know if it will be on our website, which you're exactly asking for. So let me wrap back and figure out what we can get you, and then we can think about how we make that available in the future.

That would be very helpful because what we're getting is a siloed approach, each individual silo, and we need the ability to be able to look at it holistically because this program is so broad and so detailed. So I would really appreciate that. It'll be helpful for us to make those decisions in each of those areas, understanding the problems, how they're related. So I appreciate that. Thank you.

Great. Thank you, Senator Dahle. Senator Durazo.

Thank you, Madam Chair. I've learned from my work as chair of Subcommitee Five about the issues that people involved in our justice system have to face. They're at a higher risk for illnesses and death. They have a higher risk of violence, overdoses, and suicide. The need for mental health care in our jails rose by 63%, and that overdose is the leading cause of death for people recently released from incarceration.

So my question, I don't know who, but probably from panel two, is since prison inmates will be eligible to receive Medi-Cal services 90 days prior to release, how will the state assure that these individuals are receiving the mental health and or addiction treatment services with treatment programs or community-based treatment programs when they are released from prison?

And one of the required warm handoffs from incarceration into the community is to our county behavioral health partners. So someone with serious mental illness or substance use making sure that there is a coordinated handoff from the prison, the jail, or the juvenile facility to our county behavioral health partners to ensure there is a coordinated reentry, especially since one of the pieces, for example, that we're requiring is MAT services within the jails. We want to make sure we're coordinating.

The other thing is, individuals will receive a prescription upon release. It's one of the required pieces. That way that they have a prescription when they are leaving from incarceration, and then they will have it in order to coordinate in. I would also note that all of individuals being released who go through those pre-release early services will also be connected to either a community health worker or enhanced care management, depending on the complexity of their situation.

And the idea is that we're going to build a statewide kind of justice-involved network. So we have people who are experienced in providing these services, have peers or people with lived experience or that have working with the justice-involved population. And so welcome the comments of other panelists, but those are some of the main components that we have within our justice initiative to ensure we're doing a coordinated reentry. The only other piece I would flag is with the opportunity of recuperative care.

One of the other pieces that we're hoping is if we have someone with a serious mental health condition or substance use that they can even be--or physical health condition, chronic disease--that they can be discharged into recuperative care instead of being released onto the street into homelessness. That will take time to build those connections in continuum, but ultimately, those are some of the goals of what we're trying to achieve with that new justice initiative that was just approved by the federal government.

Great. Thank you. Yeah, and I just have another question.

I think there's a couple more panels who want to answer to that. Is that accurate? Do a couple more? Okay. And please, go ahead.

Thank you. I'll just go first. Sorry. Senator, this is Kim Lewis from the National Health Law Program, and I think what Jacey says is right in that this is a new first in the country-approved waiver to do these in-reach services, and it's very exciting to see California sort of at the forefront of this investment and ensuring that people are getting these kinds of services while in carceral settings.

But is's very--and when they go into the community--but it's really critical, I think, for us to ensure that the community-based service continuum is available when they get out so that these services continue, including MAT, which is medication assistant treatment for individuals with substance use disorders, particularly at home or in communities, so that they're not just getting that in a carceral setting or in an IMD, for example.

It really needs to be part of the continuum and also some of the evidence-based approaches we talked about earlier: ACT and supportive permanent housing. A lot of these models are really designed to keep people out of in carceral settings and out of being incarcerated in the first place.

So we need to think about the front end as well as the back end of how to keep people out of that system in the first place so that we're not creating an incentive to go back and sort of repeatedly be incarcerated because of the lack of services that are available. That's really important.

Thank you.

Okay.

And Senator, I would just quickly add that this is a very novel new thing in terms of Medicaid. Again, jail-based health services exist currently, and even under this CalAIM initiative, it is the sheriff's domain, right, in county-based jail or the State Corrections Department at the state level. And so they will be working to determine which providers are housed within those carceral settings, and as Jacey mentioned, there will be certain new requirements around connections to services once folks are released. It is highly complex.

Our folks who are providing services, incarcerated settings today through county behavioral health talk about issues like, courts will require that somebody gets discharged in the middle of the night with very little notice, those sorts of things, and jail stays are often really short.

And so there are so many different layers of issues here related to making sure that folks have the right expertise to do forensic behavioral health services in these settings and outside of these settings, and then also making sure that there's adequate coordination and communication between our justice--or our jail partners, our health plans, and then county behavioral health. Ultimately, something like treatment for a substance use disorder is voluntary, and so the key is being there to catch that person when they're ready to engage in treatment.

And we've got lots of very innovative practices already, such as putting access to free Narcan and other overdose reversal products in jails, so that when people are leaving, if there's not a human there to sort of walk them to a treatment facility, if that's what they want, that they have other ways to prevent those negative outcomes.

Thank you.

Madam Chair, just one?

Yes.

Really quick. It's actually not a question. I just want to second Senator Roth's request or recommendation on the plan for the workforce issue. Almost every single person who spoke today mentioned the workforce shortage, mentioned the workforce shortage crisis, and I would include in that request where we stand on wages for those men and women who work in those critical jobs. Thank you.

All right. Now, before we go to public comment, I do have a follow-up question, so if there's any other Members that have one follow up question, we can go to that. My first comment: appreciate, Ms. Cabrera, your comments as from the perspective of the counties.

But I also wanted to--I always love to remind our counties that, yes, the jails are in the domain of the sheriffs. However, our counties do approve the sheriff's budgets and allocate the funding to our sheriffs. They also have the oversight for the jail inspections.

They have a variety of rules that involve them in this and is not--and I know you know this, but I always think it's important to point out--it is not 100 percent domain of the sheriffs, and at least in the health component of it, which we unfortunately see in a number of jails up and down the state, including my own county, Alameda, some very just really deplorable practices. So having the counties step up to their responsibility in this regard would be always welcomed and helpful.

But the follow-up question I have is that, well, first I want to say that I'm very happy that we finally have this waiver that allows us to do these services or sign up our incarcerated folks before release and to provide some level of services. This is something that many of us have been working on, I personally have been working on since 2014. So I'm grateful that it's finally been approved.

So just giving some of my colleagues the sense that sometimes these things take--you can initiate something ten years previous, and it's ten years before you see it come to fruition. So those of you who will be here for a while, hang in there and keep monitoring those things you initiate.

Anyway, so my question is, the things like the six months of housing, which would receive a 50 percent federal match, and a number of the other benefits that CalAIM could provide are now still--from what you described, many of the providers still view them as optional. So in other words, if I am a Medi-Cal recipient, it is not my right yet for those services, if I understand this. At what point are we going to get to the place where it is your right because my other care under Medi-Cal is my right?

Sure. Happy to respond to this. We actually love this question, I'll be honest with you. So when you're building brand new benefits that haven't existed before, you have to build a provider base, which is what we're doing right now. We are working on building the policies, implementing the pieces, building that growth. This is brand new, never been done in Medicaid at the level California is doing it. We often lead the charge.

And so that's the phase we're in right now: fine-tuning policy and building provider capacity across the State of California. The ultimate goal, though, is to move these 14 community supports in 15 if it gets approved through the budget process, which we are very hopeful of for the transitional rent.

To move these eventually to benefits across the State of California, we do have to see a penetration of providers to make sure that we can provide access to beneficiaries, which is why we are in this kind of growth period. So that's what we'll be monitoring. I would just flag, within the first year, we have housing navigation, housing depots, and housing liaison services in all 58 counties. So we're seeing good growth, but we still need to get there.

We're very hopeful and we are working very hard to work with our managed care plans and the providers to get that capacity, but that is the end goal, is to move all of these two actual benefits so that it is not voluntary for a managed care plan, but it is required, and that people that need services to access will be able to have it available in all 58 counties. So that is the goal that we are working towards.

And that's why the dollars getting out that just started in this year will be so critical to build that infrastructure across the state. And it looks like some other panel Members would like to speak as well.

Okay.

And if I may, just to clarify, that the rent and six months of rent in transitional housing is not live today. That is a new community support that we're proposing as part of the Governor's Budget that is before you. So I just wanted to be very clear about that, that that particular community support is not live today.

Though it's a 50 percent federal match, correct? But it's not live today. Okay. I just raised it. I think Senator Laird was implying this too, but given the number of unhoused people, California has, and given that such things as our Emergency Rental Assistance Program is now in effect done and various other--that such a tool may be one of our key ways to help a good percent of our unhoused people transition to permanent housing. So I raised it, but if any panelists can give any other thoughts quickly and then I can go to public comment.

Linda Nguy with Western Center on Law and Poverty. Just to quickly add, great to hear the Department reaffirm their commitment that the goal is to make this housing support services a Medi-Cal benefit and to move us in that direction. There is legislative vehicle out there, maybe 1085, to require the Department to request federal approval to make this a benefit. And we know that other states have already done this, so looking forward to moving toward that goal, statutorily. Thank you.

Okay. Linda. Go ahead, Linda Koopmans.

Yeah, thanks. Linnea Koopmans with LHPC. Yeah, thank you. I think one other thing, in addition to the considerations about building infrastructure, which is something where you've heard a lot about over the last couple of hours, and there's a lot of time and resources going into that locally, but just pointing out that the current mechanism that the state has used to authorize plans to select to offer community supports is through a federal rule called 'In Lieu of Services.'

So before these services were rebranded as community supports, the federal mechanism is called 'In Lieu of Services,' and why that's important is because it requires that these services being delivered, whether it's housing, navigation, recuperative care or otherwise, be essentially in lieu of a more costly Medi-Cal covered benefit.

And so I raise that because it means that right now the criteria for some of these services is pretty targeted because not only does the member need to have needs, social needs for these services, they have to be cost-effective from a medical services perspective. So many of the services that we're offering also require that you have a chronic disease or have kind of a pattern of high utilization because that is a federal requirement if these services are optional. If and when they're transitioned to benefits, of course, that's a different consideration and calculus. Thank you.

Thank you. Now, Greg Garrett, you had your hand up also. If you could respond.

Thank you, Madam Chair, and I'm going to take you, please, if I could, back to a prior question that was about eligibility and enrollment into the program, and I think this is a really critical point, and I'm going to keep it to one minute. There was a little what we would call a major challenge, I would say, between the conversion from whole person care health homes over to ECM with regard to eligibility criteria.

And that's the fact that the eligibility criteria became much more constrained and really limited the eligible population for the enhanced care management. It reduced our eligible population here at our health center by nearly 40 percent. So it was really significant that we were delivering really intensive care coordination to many members who then became ineligible. I want to thank Alameda Health Consortium, the CHCN, the Department of Health Care Services. There was an initiative launched by our local health plan to ask for an expansion of eligibility criteria. That was successful.

Our providers are able to refer members to the health plan and have them reviewed, and many now are becoming eligible who were not originally on eligibility lists. And this is really important because I heard other presenters talking about individuals having issues or constraints and becoming eligible for the program or enrolling.

So if nothing else--and speaking with Scott over at the Alliance--and what could be said in this presentation, it's just to encourage other counties to explore similar opportunities to expand eligibility criteria, similar to how the Alliance did. Thank you to DHCS for being receptive to these requests, and it has really expanded the eligible patient population so that we can deliver services to our members. So just wanted to put that little word of recommendation in there.

Thank you, Greg. Appreciate it, and Kim, and then I'm going to go to our public comment.

Just very quickly. Thank you, Senator. I think, and maybe Jacey didn't quickly speak to this, but In Lieu of Service is the tax loan, which is the way the federal government and the federal regulations talks about these community supports that we call them.

There are also some elements of these require federal approval to be in place, like through an 1115 waiver from the housing pieces that get funded with a federal match because they're not otherwise coverable under Medicare. And so I think that's not always just a budget issue, but also a federal process to get approval, so I wanted to just raise that.

Thank you. And maybe, Jacey, if I gave an example, and you can tell me if this is correct. So say we have this new community benefit for the six month of housing, say, approved, and a practitioner might say, 'well, this person needs rehab,' so could it be that they might qualify then for the housing and a daytime program that is less expensive than a residential rehab? Would that be the kind of thing like, in lieu of or not? Jacey?

Yeah, potentially. The idea of In Lieu of Services is that it's medically appropriate and it's cost-effective, and that you are, by providing the service, avoiding a higher cost service, if that's helpful. So why there's the intersection with the various pieces.

What I would flag to Kim's point because I think it's an important one for people to understand is that while we have the authority for the community supports through, it's a simple 1915b and a contract for the In Lieu of Services, there are two in the 1115.

But we had a huge win at the beginning of this year where CMS approved those community supports as what's called budget neutral, which means we don't have to have savings to pay for them into the future, which means they can be a benefit in the future, which is really important. We want people to know that there's a sustainable funding pathway for these things, and that would include where transitional rent is going to go.

So I just wanted to tie those connections for people so that we don't want providers thinking that this is going to be ebb and flow. There is a pathway for long-term funding tied to these things. Now we need to make sure we're building the capacity and the outcomes, of course, but just wanted to make sure that that was clear and we would do the same for any of the community supports. I just wanted to point to Linnea's comment.

We were able to demonstrate to CMS through extensive literature review that these community supports, while the intersection is on their face, medically appropriate and cost-effective, which means you can do them from a preventative nature as well, so it doesn't have to be at the individual basis. We had a broad base, convinced the federal government that they are medically appropriate and they are cost-effective.

That is why you can't just add anything to the community supports list because we need to make sure that we're not supplanting other systems that are maybe social services or other areas' responsibility, but making sure that's intersection. So hopefully that's helpful context in regards to how we're thinking to move them to the benefit and the long-term sustainability of these benefits as well.

All right. Great. Okay. We are now going to move on to public comment, and I want to give the participant number for those of you who are calling in. That number is 877-226-8163. The access code is 4400595, but we will start with public comment from those who are physically here in the hearing room. So those who want to please line up, and I would ask if you could keep it to a minute. Go ahead.

Absolutely. Thank you, Madam Chair and Members of the Senate Budget Committee. Jedd Hampton with the California Association of Health Plans, which represents 44 health care service plans that collectively provide coverage to nearly 28 million people across the state. We'd like to thank the Committee for the opportunity to deliver public comment on today's CalAIM hearing cap, and our managed care plan members are firmly committed to the successful implementation of CalAIM and are working tirelessly with the Administration on this innovative program.

In the interest of keeping it brief, I will go directly to our comments, specifically around the Enhanced Care Management program. First, it's important to note, as many others have here today, that this program is relatively new. It's only been in effect for over a year, and all new programs, especially one as transformational as this one, take some time to ramp up and fully implement.

Certainly, this program is no exception, as evidenced by the fact that several components of the Enhanced Care Management program have not gone completely live as of yet. Specifically, the children and youth populations of focus do not go live until January--excuse me--July of 2023, and this is important to highlight because children and youth make up a substantial portion of the eligible population. Secondly, many new provider types operating within the ECM framework are relatively new to managed care.

And as you've heard today, managed care can be a relatively complicated system. So we are continuing to work with--educating and contracting with these new providers and are encouraged to see that providers are getting involved at various levels as we continue to see more and more providers onboarding. And lastly, we want to ensure that all stakeholders have realistic expectations for the program moving forward.

We believe that lead lists and provider referrals will continue to improve over time and as this program matures, we expect to see more enrollment into the program moving forward. So we continue to look.

You can wrap up please.

Looking forward to working with all stakeholders above. Thank you.

Next.

Good morning. Michelle Gibbons with the County Health Executives Association of California. We represent local health departments across the state. Appreciate the discussion here today and for the Department's leadership in implementing CalAIM. We know that this is a huge initiative and there's many moving pieces.

In several jurisdictions, local health departments were the lead entities in whole person care, and so we are just looking to continue to support the vision of CalAIM through continuing to have partnerships with the health plans, but to also coordinate and/or be the service providers as well. We appreciate the Department's approach on the population health approach. We hope that the Department and health plans will leverage the knowledge and the work that public health departments do in this space to really ensure that it can be meaningful.

We are also interested in supporting public health departments to be positioned as critical ECM providers for key populations, many of the populations that are upcoming that we already touched, like the CCS population or the birth equity populations, and we just would ask that you all consider, and that the Department and plans consider investments that are needed in health departments to come up to speed on things like Medi-Cal billing practices and navigating contract negotiations with health plans.

These are new spaces for local health departments, despite the fact that we have expertise in the work. And lastly, I would just say that we appreciate the continued engagement and we hope that health departments will be looked at as meaningful, critical partners in these efforts. Thank you.

Thank you.

Kelly Brooks, commenting on behalf of the California Association of Public Hospitals and Health Systems. For more than a decade, California's 21 public health care systems, which include county-owned, operated, and/or affiliated facilities, and the University of California medical centers have been leaders in Medi-Cal transformation. Most recently, public health care systems were the lead entities in California's Whole Person Care program, a statewide effort to address social needs alongside physical health for some of our most at-risk populations, including individuals experiencing homelessness.

Our work in Whole Person Care laid the foundation for CalAIM, and we are eager to build on that success as core providers of Enhanced Care Management and community supports. Under CalAIM, we look forward to closely working with our health partners, community-based organizations, and other stakeholders to continue caring for people with complex health and social needs. Thank you.

Thank you.

Thank you, Madam Chair and Members. Jolie Onodera with the California State Association of Counties, representing the 58 counties. I'd like to--CSAC appreciates the Legislature and the Governor's commitment to the critical investments made to support the CalAIM initiative. I'd also concur with the testimony today from the panelists highlighting both the challenges as well as the opportunities for this multiyear and multi-pronged initiative.

I'd like to express county support for the 375,000,000 dollars for the Behavioral Health Payment Reform that will be so critical to counties as they transition to this new system July 1st of this year. Additionally, would also express support for funding for workforce development programs that are so critical.

Lastly, just wanted to note that the counties do recognize the opportunities for the behavioral health continuum--community-based continuum waiver demonstration and look forward to the continued partnership with both the Administration as well as the Legislature on those issues. Thank you.

Thank you.

Madam Chair and Members, Amy Blumberg with the California Children's Hospital Association. I'd like to provide comments today regarding concerns with CalAIM implementation with respect to the California Children's Services program. CCHA opposes the Department's proposed Whole Child Model Expansion trailer bill for three reasons. First, the Department agreed as part of SB 586: Hernandez of 2016 that Whole Child Model would not be expanded until the Department has conducted a thorough evaluation, and that evaluation has not been released, although it was completed last June.

Second, the CCS program provides many important services for critically ill children and their families, including knowledgeable county CCS case managers who understand the unique needs of these children. Expansion of the Whole Child Model deprives children and families of these expertise. Third, Whole Child Model results in Medi-Cal supplemental payment cuts to children's hospitals because provider fee payments to hospitals are adjusted for acuity when services are provided in fee for service, but are not adjusted for acuity when CCS services are in managed care.

And, for example, this will result in a cut of about 25 million dollars in Medi-Cal provider fee annually to a children's hospital in Southern California, and with the expansion of Whole Child Model to Alameda County, will result in a provider fee loss of 28 million to Northern California Children's Hospital. So we have a number of concerns, and we'll follow up with a letter.

Thank you.

Good morning, Madam Chair and Members. Karen Lange, on behalf of the Solano County Board of Supervisors, here on a very specific issue that affects Solano and Sacramento counties. Your staff is very familiar with the problem. As part of CalAIM, the Administration is trying to give back to Solano and Sacramento counties the severely mentally ill people that the state has been procuring services for for decades.

That population was never a factor in the 2011 realignment, and in January of 2023, the State Administration decided to take a chunk of the growth money in the realignment formula and give it to the two counties, which meant that the other 56 got less so that the two counties could get a fraction of what they need to take care of this population. We are on a speeding course towards July 1st when the state wants the counties to take it over.

They haven't had any money made available to them until January, and it's only less than a third of what they need, and it's going to leave several thousand of the most severely mentally ill people in Solano and Sacramento counties in the hands of those two counties without an ability to provide care for them. And as you've heard repeatedly this morning, there's a workforce shortage, and the counties are going to have to go out and find doctors or procure contracts to serve this population.

That's going to take months and months and months, and they haven't been able to get that far because they don't have the money, and so we're asking that as part of the Subcommittee process, we get to do a deep dig on this issue and get to where we can find some money for these two counties because at the end of the day, these are vulnerable people and we don't want to do any harm. Thank you very much.

Thank you.

Madam Chair, Members, thank you. Steve Horne, President of the California Medical Transportation Association, and wow, what a project CalAIM is. But I can tell you right now that it has started off with a huge failure as it comes to the dual eligibles and the transportation primarily of the chronically ill going to and from dialysis. Currently, it's February 22nd. The majority of these dual eligibles were transferred as of February 1st. Many of them still do not have rides to and from dialysis.

And the Department, the plan was that the eligibilities would transfer over through the year of 2023. But somebody decided, 'hey, let's do it all in the month and become effective February 1st,' and the majority of these members were not able to arrange transportation. Transportation providers throughout the state were helping dialysis clinics and social workers and the individuals to try to contact their new insurance company. And they said, 'hey, we haven't even been notified that you're our member. We can't do anything until the 1st.'

So again, thousands of people have been left without transportation. And I don't know if you've got the data on missed dialysis appointments, but it has serious health impacts on them, and I believe somebody needs to look into that right away and get a resolution on that.

Thank you.

Madam Chair and Members, John Wenger, on behalf of the National Coalition for Assistive and Rehab Technology. We're the trade association for the providers and manufacturers of complex rehab technology, which is highly customized equipment for adults and children with severe physical disabilities, like ALS, multiple sclerosis, spina bifida. We're very excited about CalAIM and the prospects of it for our patients. It's a very difficult delivery model that we face. We do have concerns, continuing concerns on reimbursement. We're under durable medical equipment, which is purely equipment.

And so the reimbursement model doesn't give us any reimbursement for transportation costs out to the home, for all of the labor costs related to the team of providers that it takes to actually deliver and fit the customer. And so we do have some reimbursement concerns. I know the Medicare fee schedule had about a 15 percent bump for inflationary reasons. That's not being adopted by the Department. So there's some concerns there. We also have a few concerns around outcomes measurement.

We'd like to see a statewide kind of across the board outcomes measurement system for CRT patients. We think that could be done through like, a functional mobility assessment across all plans, and so we'll follow up with the Department and the health plans on that. Thank you.

Great. Thank you. So we'll go to the phone lines now, and, apologies, we have very little time left, but Operator, if you could queue up anyone you have in the phone line.

Thank you, Madam Chair. We have people who've already queued up to ask a question.

Then please proceed.

If you have not pressed one then zero, press one then zero at this time. We're going to go to line 26.

Hello. Good morning, Madam Chair and Members. My name is Sharon Rapport. I'm with the Corporation for Supportive Housing. Housing support services, which are offered through CalAIM's community supports, have been proven to improve the health conditions of Medi-Cal enrollees who are unhoused. While CalAIM was a positive step in offering housing support services, the Medicaid authority the state uses to fund services is complex and imposes barriers to accessing services, sometimes with inequitable results. Managed care plans restrict eligibility to ensure sufficient return on investment to pay for the services cost.

We agree with Ms. Nguy that the next step for the state should be to create a housing support services benefit, a benefit that offers services based on need rather than return on investment. A benefit would bring significant federal resources to California and scale up services funding. The HCSF has also identified a goal of creating a housing support services benefit, so we urge the state to move in this direction and to fund the cost of seeking federal approval. Thank you very much.

Thank you.

Line 29.

Stephanie Whitten with SEIU California. Thank you for the information and in particular the discussion and comments around the workforce, and specifically, thank you, Senator Durazo, for highlighting the need to good paying, high growth jobs. We would just underscore the importance that the state ensures proper funding and potentially increased funding for the overall Medi-Cal program, and calling in order to ensure the workforce can appropriately address the needs of recipients and get individuals enrolled in the program to address their specific needs. In order to help programs, we must invest in the workforce on , rather than waiting to see what happens if the programs are not adequately funded. Thank you so much.

Thank you very much.

Line 36.

Good morning, Madam Chair. This is Felix, at Benefit Medics, one of the California's nonprofit health information organizations or HIOs for short. We're very grateful for this hearing, emphasizing the need to build infrastructure to enable the equity and quality transformation that CalAIM envisions.

And one of the recurring themes in all the presentations is that the beating heart of CalAIM is truly the ability to share and to use electronic information. This includes traditional medical providers and health plans, as well as their new partners like CBOs, social service providers, and county agencies. Now, we and other California HIOs have the right tools and expertise to deliver this infrastructure, but we get no financial support from the state budget.

Particularly, the Administration has not yet proposed some widely known and available funding blueprints for HIOs that can also draw down some extremely generous federal matching funds. So as you continue your budget oversight and work towards your decisions, especially in this scarce environment, we urge you to pair CalAIM with the highly federally matched funding needed to build this data infrastructure that's critical to its success. Thank you.

Thank you.

Line 37.

Hi there. Thank you. Paloma Sisneros-Lobato with SPUR, public policy nonprofit based in the Bay Area, and I would like to elevate medically-supportive food and nutrition as the third most utilized community support in the first year of implementation. Medically-supportive food nutrition refers to a spectrum of food-based interventions such as produce prescriptions, food pharmacies, and medically-tailored meals. In action, this can look like a pregnant person visiting their doctor and being diagnosed with gestational diabetes.

Instead of just being told to eat healthier, the doctor can actually provide the patient with a fruit and vegetable voucher known as a produce prescription. This allows the pregnant person to visit the grocery store or farmers market to redeem that prescription for free fruits and vegetables. And a study completed in San Francisco shows that this has the power to reduce the rates of preterm birth by 37 percent.

This is just one example of the benefits of medically-supportive food nutrition as it relates to a benefit through CalAIM. These interventions can both improve health outcomes and produce cost savings. For example, researchers have estimated subsidizing healthy foods could save 40 billion dollars to 100 billion in health care costs nationally. We see medically-supportive food nutrition as a really important community support available under CalAIM. Thank you so much.

Thank you.

Line 12.

Hello. Good afternoon. My name is Tracey Rattray. I applaud CalAIM's transformation to address the social determinants of health. That said, if we truly want to advance health equity and contain health care costs, we must invest in programs that reach beyond individual Medi-Cal members and improve community conditions that prevent people from getting sick in the first place. Sustained investments in California's tobacco prevention policy work demonstrate that prevention works. Among other things, tobacco control created smoke-free environments, reduced youth access to tobacco, and reduced aggressive marketing in communities of color.

The result: over one million California lives saved and 134,000,000,000 in health care costs avoided. My question is, 'will there be an opportunity to expand community support to include prevention strategies that go beyond individual patients and support creating healthy environments?'

Appreciate that. We will submit it to the Budget staff and we will get back to you. Moderator, the next comment, please.

Line 37, your line is now open. Line 34, your line is now open.

Hello, Madam Chair and Committee Members. Thank you. This is John Drebinger, Senior Advocate with CBHA, the California Council of Community Behavioral Health Agencies. I just wanted to provide some comments in support of our CEO Le Ondra Clark Harvey's testimony regarding challenges CBOs are experiencing related to CalAIM implementation, and also to thank the Senate for providing a forum to discuss the ongoing collaboration needed with community-based organizations, counties, and the Administration.

As Dr. Clark Harvey mentioned, that AB 1470: Quirk-Silva is an opportunity for the state to make it easier for providers to deliver Medi-Cal services by standardizing documentation statewide. We wanted to thank you for your leadership on these issues. CBHA will continue to be a voice for behavioral health providers across the state, and we look forward to partnering with all stakeholders, including this Committee. Thank you.

Thank you.

Line--we'll now go to line 30. Your line is now open.

Good afternoon. Corey Hashida with the Steinberg Institute. We're an independent, nonprofit public policy institute dedicated to transforming California's mental health and substance use care systems through education, advocacy, and accountability and inspired leadership.

Just want to comment to signal our strong support for the Administration's California Behavioral Health Community-Based Continuum demonstration proposal. The new community-based services included in this project are critical expansions of care that will save lives, and the proposal simultaneously helps ensure that institutional care is provided as a last resort. We also appreciate the proposal's focus on accountability, performance improvement, and standardization of measures and practices. Thank you.

Thank you.

Now move on to line 28. Your line is now open.

Good afternoon, Madam Chair. Nora Lynn on behalf of Children Now. Children Now appreciate the vision and goals of the CalAIM initiative, especially given the long standing deficiencies in children's utilization of preventive care and Medi-Cal that the auditor has reported on.

We share the operational concerns around implementation that have been pointed out by today's panelists, and we look forward to working with DHCS and other stakeholders to ensure children and youth consistently have equitable access to quality-coordinated, medical behavioral health and dental care. Thank you.

Thank you. Moderator, I believe there's one remaining. None?

And once again, ladies and gentlemen, if you did have a question--

If that's--Moderator, if that was the last you had in queue, then we're going to stop. Since I technically should have stopped at noon, I'm very appreciative that we were able to fit in those people who had been queued. I'm very appreciative of that, and I want to thank the panelists very much. This was a lot of information, I know for myself, I'm sure for my colleagues, and it was a very important hearing for us to hold. We don't always have the benefit to get into the detail. Certainly the Subcommittee does, and my Subcommittee Chair is sitting right here on the dais.

But I think it will help the rest of us as we look at, as we basically plan out the Legislature's approach to these things for the 23-24 budget. So appreciate everyone, all the panelists, staff; thank you so much for the arranging it, and members who are still in the room, thank you for hanging in there. And with that, I will conclude the Senate's Budget and Fiscal Review Committee hearing for today.