Senate Standing Committee on Health

The Senate Health and Public Safety committees will come to order in 10 seconds. 9876321. Okay. The Senate health and public safety committees will come to order. Oh, there it is. You heard it right. All right, welcome. Today we're going to be talking about CalAIM in 2022. Our great state was looking to advance and innovate Medi Cal. That's where we got CalAIM from. And it was launched with great intention.

We're looking to uplift individuals on Medi Cal with the highest needs, connect them to those community services, make sure that we're looking at their holistic needs, the wraparound services that it's not just a one and touch and how can we be more sustainable, long lasting with our impact?

We wanted to streamline this program and wanted to address the social drivers behind what is causing someone's pain, whether it be physical or mental. And we were looking to incentivize Medi Cal plans to be part of that focus on quality care.

So we authorized was this program was authorized through two federal waivers and we got amendments to our state Medicaid plan. Now we are three years in and we are about a year and a half away from it potentially ending. And we want to see where we're at. So this is not a CalAIM 101.

I hope we are completely done with CalAIM 101. This is more of a where we are now. How can we move forward? Can we do any further tweaks to this program? We want to make sure we're meeting the goals of Calaim that everybody in this Assembly streamline is working together.

And this also allows a platform for people that perhaps takes them a long time to get respond to an email, you have to talk to this person or that person, come to the table all at once and have a discussion on how we can move forward better.

We will start with a justice involved reentry initiative focus which is why you see my great colleague here to my left joining me. Because the program allows for eligible individuals who are incarcerated to enroll in the program and to re receive targeted set of services 90 days before they get released.

It's an effort to reduce the barriers that once you're released you have a social net network that you can continue get services from and not just be left to fend for yourself. So now I'd like to turn over to my co chair for any opening remarks on his end.

Well, thank you Senator Menjivar. Calaim is an ambitious overhaul of our state. State's medical system to provide care to millions of Californians, including some of our most vulnerable populations, many of whom have complex health conditions.

And so, as the chair noted, we'll hear updates from state and county partners, treatment providers, consumer advocates and health plans about the rollout of three specific CalAIM initiatives. And as the chair of the Senate Public Safety Committee, I'm particularly interested in the implementation of the Justice Involved Reentry Initiative.

And this is, I think, particularly important to me as somebody who represents Alameda County, given some of the challenges we've had in providing behavioral health and public health services for people in our county jail system. And so I'm really excited that this initiative is unfolding.

We know that justice involved individuals face unique challenges, and I'm particularly looking forward to hearing from our panelists about how efforts are being coordinated to best serve this population. This is really challenging work, especially in the context that we're in now. But it is critical work.

So I want to thank all of our panelists for joining us today to provide this important information. I'll turn back over to the Chair.

Thank you, Mr. Co Chair. And you know, California is leading in that this is the first ever in the nation kind of program. So with that, you know, there's always some hiccups that we got to go through. All right, colleagues, any other additional opening statements? Great. Seeing none.

So we're going to hear from all our panelists on the agenda prior to taking up any public comment. Once we've heard from everyone who's going to be testifying today, we will have the public comment period. And then that would be your time to come up and tell us your dreams and your wishes.

So we'll have the first panelist on Justice Involved Reentry Initiative come up. And here we go. This is me. I apologize in advance. I will be pronunciating your names best of my ability. Joining us today is Vitka Eisen, the President and CEO of HealthRight360. We have the public health officer from Yuba and Sutter counties.

That's going to be Dr. Phuong Luu. We have the chief from Sonoma County Probation Department, Vanessa Fuchs, the Director of Legislation and Special Projects from CDCR Director Lisa Heintz. And then later we'll be joined by our. oh, you're right here. Great. You're right here. No, no, no, no, no. It's because I thought you weren't here.

So later she'll come up, Director Michelle Baass from our Department of Healthcare Services. All right, we'll start with Vitka, whoever there we go.

Hi, my name is Vitka, Vitka Eisen. I'm the President CEO of HealthRight 360. I want to thank the co chairs and the Committee Members for having this hearing. I want to give a shout out to my former mayor, Berkeley Long, long, long, long time Berkeley resident. It's great to see you up there.

Let me just tell you so. Health rate 360 is one of the largest union organized nonprofit behavioral health providers in California. And we operate a broad network of services that include community reentry programs that support individuals navigating the difficult transition from incarceration to community life. As we have done since the mid-1990s.

This justice involved the JI initiative and its approval by the feds is very exciting and it's, it's what makes me proud to be a Californian because I think it paved the way for enhanced services across the country, potentially for people transitioning from prisons to community.

Today I'm going to talk specifically about the interface with the state Correctional system or CDCR. It's a tremendous opportunity we have to improve transitions from correctional settings to community to improve health outcomes. We could optimize this service and consider. We recommend optimizing this service to consider establishing regional hubs.

A regional hub model to help the interface with the correctional facilities back into community. These hubs will streamline the 90 day in reach process and ensure seamless transitions. And it is similar to models that CDCR has operated before in terms of using coordinating entities. For example, they've used this for their substance use treatment programs.

Coordinating entities that could manage moving people from one part of the state to their home. Community hub model solves inherent challenges to the success of the JI initiative. For example, I'm sure you're aware of this.

There are what, 20 plus managed care plans, not counting pace programs, 20 plus managed care plans operating in 58 counties soon to be released. Beneficiaries will be enrolled in one of those plans from 31 different prisons and 36 different fire camps spread across the broad geography of California from Del Norte to Imperial County.

That in and of itself is a challenge. Beneficiaries must return to their County of last legal residence, right? So depending on where, no matter where you did time, you will be returning to where you last lived.

This means that a beneficiary incarcerated in far northeastern California will need to be enrolled in one of, let's say for plans available to them in Los Angeles County. The gap between referring entity and receiving entity is a long distance.

Finally, managed care plans have Further contracted with multiple local entities, many, many, many providers on the ECM side to serve as their ECM partners. As a result, for the JI beneficiaries being released from CDCR, there are multiple opportunities for warm handoffs to grow complicated and cold.

So the hub model aims to solve those challenges by establishing regional hubs. It draws on, as I said, a successful model that CDCR has used in the past to case manage people from every single prison back to their home county and ensure that they get services. It will help assist with the 98 day in reach service.

It helps provide a seamless transition. I know I don't have much time, so I'm going to talk fast and I also will leave this with you. And it will also help with the standardized contracting process. As you know, each plan, different contract, different demands, different kind of billing process, et cetera for the managed care plans, streamlined contracting.

If the mcps contract with three leading entities instead of literally dozens and dozens and dozens of ECM providers, it reduces administrative burden. It's also you can ensure some kind of standardized delivery. And now it doesn't eliminate local ECM providers. This is really the bridging service where you can help get people from prison into a local community service.

And finally it'll improve health outcomes for the state. I think it helps ensure efficient coordination. It also allows us to maximize the federal funding.

For example, a person who is enrolled in the ECM program who was leaving a prison, let's say, in far Northern California, and would actually need to be for a best outcome, transported down to their home county, let's say, back in Alameda County. The plans can be billed to pay for the transportation.

And we know from years of experience that when you pick people up from an institution and you get them to the place they want to go, you're already dramatically improving their outcomes and their health.

Final thoughts?

Yes. So by establishing three regional hubs, the concept creates a more efficient, scalable and effective system for delivering justice involved in reach services for the betterment of all Californians. I have more details in this. I will leave this with you.

Dive into more with the question.

Yeah, yeah. But thank you. Thank you.

Next up, I'll turn to our Dr. Phuong Luu, the public health officer.

Good afternoon. Can you hear me okay? Yes.

So good afternoon, co chairs and Members, Committee Members, it is my honor to present today on behalf of Yuba county efforts to implement the first in the Nation, Cal Am Justice Involved initiative as one of the three counties that went live within the first cohort as of 10-1-2024 Yuba county is proud to have been able to serve more than 500 incarcerated adult inmates and juvenile detainees for medical and behavioral health, clinical services and reentry care coordination.

As clinically indicated, we have been able to provide each CALAM justice involved enrolled and willing justice involved persons with medications in hand before release, follow up appointments for primary care, mental health care, substance use disorder treatment and coordination for a variety of social services such as enrollment within our local Homeless coordinated entry and CalFresh CalWorkh et cetera.

We can have such a strong start due to the deep engagement and collaboration across our Sheriff Department, Probation Department, Behavioral Health Department and Health and Human Services Agency that has both Public assistance and my home Division of Public Health.

We are also grateful for the close coordination with our local FQHCs, one of which serves as our designated Calamity justice involved in reach provider and our two Medi Cal Managed Care, the predominant one being Partnership Health Plan and also Kaiser Medi Cal.

We are invested in addressing the health and care coordination needs of the justice involved population in Yuba county and have high hopes for the success of this program. However, there are several issues that are top of mind for us as we assess the long term sustainability of this transformational program.

First, we are grateful to the past justice involved funding. However it is one time funding only and it is unclear how our county justice involved initiative can be sustained when this funding ends.

It is unknown if the Medi Cal fee for service rates for pre clinical clinical services programmatic will cover our increased staffing and programmatic costs to implement this whole person comprehensive program.

Secondly, and also on the billing claiming side, we are concerned about the Low rates of the five reentry care bundles that our in reach provider must rely on to Bill for all pre release reentry care services and also post release services.

If our in reach provider cannot sustain the staffing model due to the Low fee for service rates then this jeopardizes their involvement in the long term within our county justice involved program. If our inreach provider exits, we cannot meet that gap. We have no staffing and no capability within Yuba County.

Finally, the transition from Medi Cal fee for service and managed care has not been seamless at times taking more than 30 days for the transition to occur. So while they're incarcerated they're under fee for service. Ideally immediately upon release they should go into managed care. That's not happening.

So that gap in terms of the transition has really left us challenged in terms of continuity of care because many of the services that we rely on ecm, community support, managed care available transportation services is only going to be allowable as long as they can actually be seen on the managed care roster.

So I can't expect partnership to cover transportation if it's not on partnership roster 12 days post release. So then that leaves us within the fee for service transportation network. And that network, especially in our rural county Uva County, is sparse or at times non existent.

So in conclusion, I thank you for this opportunity to present to the Senate and Public Safety Committees and I'm available to answer any questions you may have. Thank you.

Thank you so much for that, Doctor. Now I'd like to turn over to Vanessa Fuchs, Chief from Sonoma Probation Department.

Good afternoon co chairs and Members. I'm Vanessa Fuchs, the Chief Probation Officer of Sonoma county and I'm here on behalf of the Chief Probation Officers of California. Thank you for the opportunity to speak today about some of the challenges we are facing in implementing CALAIM within probation and some of our recommendations for implementation, streamlining and improvements.

Central to the initiative is the goal that justice involved individuals get the supports, services and tools they need to be best positioned for safe and successful community reentry. Safe and successful community reentry is our mission and probation has long understood that this form of reentry cannot be achieved without access and connection to these integral supports and services.

Probation departments will have different pressure points with implementation based on how their local justice system systems choose to approach the work. Some examples are Some probation departments are looking at how to incorporate this initiative during our work on pretrial.

Some departments are involved or even embedded in the county jails for reentry services and the adult case management services that follow release. We have at least one Department, Lake County, that has been approved by DHCS as the Enhanced Care Manager and other counties are analyzing the cost benefit of this.

I would also note we understand CDCR is planning on going live soon, but half of the population leaving state prison will be under probation jurisdiction and we have not yet learned what the workflow or process will look like for those individuals statewide.

We have noticed some themes in the implementation process where significant obstacles have presented that we need your understanding and support to overcome. Number one, service coordination and linkages have been a major hurdle ensuring continuity of care for justice involved individuals during their transition from custody to community.

As it is complex work, particularly when multiple partners are involved, justice involved individuals have many re entry needs that probation is coordinating for people as part of their court ordered requirements and to bridge services. So we must ensure that plan requirements don't interfere or add complexity to meeting all the reentry goals.

The key to ensuring this is to mandate coordination and communication between plans and probation. Second, our workforce and training needs cannot be understated. Probation staff require specific targeted training to understand CALAIM services, referral processes and managed care requirements. The state should develop training to the unique challenges we face within the justice system.

One of the most pressing issues we face is data sharing and privacy barriers. CalAIM's focus on whole person care requires robust data exchange between probation healthcare providers and managed care plans. However, data sharing restrictions like HIPAA and 42 CFR. Part 2 Create roadblocks. The State needs to find ways to remove the barriers of sharing information with probation.

Number four. The State has yet to establish specific reporting guidelines for each correctional facility, making it difficult to plan and implement accurate data collection systems. We ask the state to provide clarity on reporting requirements. Number five and finally, there are significant funding and sustainability concerns.

As you've already heard, prob departments often lack the dedicated administrative resources to meet the new and additional requirements. It is unclear whether revenues from Medi Cal Billing will be enough to cover the ongoing programming and positions needed to meet Cal AIM's requirements and the additional costs of building building billing capacity in correctional facilities remains a concern.

We would ask the State to look for ways to improve billing operations or long term access for probation costs to implement this initiative. Regardless of the CALAIM Justice Initiative, probation must still deliver on safe and successful reentry.

We would hope CALAIM will enhance our ability to deliver on our mission for the benefit of those we serve, which will also result in helping long term public safety. We respectfully ask for your continued support in addressing these challenges so that we can truly create a more effective integrated system of care. Thank you for your attention to these issues.

Thank you so much Chief. Now turn over to the Director from CDCR, Ms. Lisa Heintz.

Thank you Chair and Co Chair Good afternoon. Lisa Heintz, Director of Legislation and Special Projects and the Project Executive for the CalAIM initiative for CDCR CCHCs I want to first thank this legislative body for its continued support of the Department's rehabilitative programs and their commitment to the CALAIM Initiative to focus on enhancing our pre release and reentry services for the population we serve.

Over the past year the Department continued its partnerships with dhcs, Community County based Providers, Managed Care Plans and under the Calium Initiative. Our Go live date, although originally scheduled for January of 2026, occurred in Phase 1 this last February 32025.

That's due to the extensive expertise of our IT infrastructure, the PATH funding that was allocated to the Department to allow us to become a billing and claiming entity. Under the CalAim Initiative.

We completed Tabletop ex with county CBOs and partners and after receiving our Conditional readiness assessment from DHCS, we are geared to go as of February 3rd, we have submitted 1,538 claims for medication reimbursement and expect a reimbursement total of $77,000.

As you are aware, justice involved populations and as everyone here has stated, particularly those releasing from prison have significant health and behavioral health needs with significant cost to the and counties. The interesting part about our population is the majority of them leave in a stable condition.

We are under a federal court receiver and they have advanced medical and mental health treatment at the time of their release.

The CalAIM initiative, however, is the next critical step in successfully supporting the transition of our justice involved populations returning to our communities and we are excited that once fully implemented, Calhoun will help us address all the health care and supportive services gaps we have seen in reentry services over several years.

We believe the Department's coordinated hybrid care model allowing the releasing person to connect to enhanced care management services during the last 90 days of their incarceration to finalize their reentry plans, discuss ongoing care and identify individual community supports needed, will maximize the CalAIM impact and reimbursement.

CDSR's Phase 2 implementation will begin April 1, 2025 and includes case management services and Bill. This includes the warm handoff to the ECMS and county behavioral health departments when appropriate. Phase 3 implementation will begin July 2025 where CDCR will be able to Bill for clinical services such as laboratory radiology and physical and behavioral health clinical consultation services.

CalAIM presents a one of a kind opportunity for California to standardize direct linkages to care and the justice involved population and establishes a statewide network to ensure supportive services are available to those releasing from the criminal justice. I appreciate your attention to this matter and I'm happy to answer any questions.

Great. Thank you so much Director. Moving on to another Director, I appreciate you writing some responses, saw you writing some notes. We wanted to put you at the end to give you opportunity to respond to some of the comments that were mentioned by the first panelist.

And I invite Deputy Director Autumn Boylan who is our lead at the Department on this initiative. So she will also on some of these questions. But before we begin, just wanted to note, I think it's already been raised that this is just really first in the nation.

Groundbreaking, really uniting two desperate systems who have really never had to engage in the way we are engaging today. Not only prisons but jails, probation, all of our providers, public health, et cetera. And it is. I can't under overstate how much work has been done and how much work still needs to be to be done.

The policies, the procedures, the federal requirements of our different entities really as we think about how we deliver and how we improve. Appreciate this conversation because we do want to improve. I think just noting four counties are live, three went live in October.

So that's Inyo Santa Clara and Yuba and then San Joaquin went live in February of 2024. And then CDCR the first phase again in February. Just some stats just to get a sense for how many people really have been impacted. So far, about 6,500 Medi Cal Members have received Medi Cal pre release services.

So 6,500 people now are getting these services that we're talking about, those four counties and CDCR we are getting claims for pharmacy, claims for services.

So just this huge opportunity to really do this in reach, provide those connections just in those four counties and the first phase of CDCR over the course of the next year or so, year and a half, all counties will come online by October 1, 2026. So this is a phased kind of process. Not everybody is live today.

And so time to really think about what are the lessons learned, how do we improve on as we continue to roll this out in the state. I'm going to Autumn to really get into some of the specifics that have been raised and happy to engage as well.

I'm happy to be here with you this afternoon. And thank you to our other panelists for your comments today. I would just echo what Director Baass said a moment ago that this is an unprecedented first in the nation initiative that we and it is a demonstration project under our 1115 waiver, which means that we are learning as we demonstrate.

And I think we've learned a lot already from the work that we've done in Yuba, Santa Clara and Inyo counties. We've learned a lot through our conversations with California Department of Corrections rehabilitation about what it's going to take to actually operationalize and make real the outcomes that we've aimed to achieve through this initiative.

And so I think, you know, to Director Boss point, there is still work that is being done to address some of the comments that we've heard specifically this afternoon, including kind of the bridge between how we get from the one time PATH funding, which was really meant to be an initial investment of $561 million to support correctional facilities and county behavioral health agencies across the state to be able to stand up the necessary infrastructure for this program so that they could phase in over this two year period that's inclusive of things like Director Hines mention where building infrastructure for billing, for example, without the PATH funding, much of that infrastructure would not exist since correctional facilities had not previously been able to Bill Medicaid for services and draw down federal funds.

So those one time dollars, while they are one time and not meant to sustain those types of Long term investments around staffing and other issues raised today, like transportation does provide the initial kind of seed funding to make the necessary infrastructure investments to invest in system changes and IT enhancements that are necessary for the long term billing.

And although Medi Cal rates through the fee schedule and the Medi Cal Fee for Service Delivery system, which is the basis for reimbursement for this program, may not cover costs for the services, it is all new federal funding that is becoming available to support services in correctional facilities at all levels, including the state prisons and the county correctional facilities.

And so there we I think will learn as our correctional facility partners in the counties and in the state continue to Bill for services what what those additional resources can support.

We're also looking to see what other infrastructure at a state level we can leverage through, through negotiations with Centers for Medicare and Medicaid looking at things like seeking approval for a Medicaid administrative activities claiming program that would provide more ongoing resources from an administrative perspective. Of course those are things that we have to get approval for.

Since California is the first state in the nation to do this, there's a lot for the Federal Government to also contemplate in terms of what it's going to take to roll this out.

And to that end, DHCs and CDCR along with Los Angeles County have been working in a collaborative partnership with states who are also implementing the reentry Demonstration Waiver so that we can, across states collectively learn from this experience and advocate on behalf of states for what it's going to take to operationalize effectively this program and achieve the outcomes that we have all set forth to achieve.

Some of the other pieces that I think were raised this afternoon around transportation and some of the limitations, you know, I think we, in terms of the fee for service delivery network, you know, we are very committed in terms of not just this program but at large to making sure that our Medi Cal Members have access to Medi Cal covered services, including transportation for non emergency medical transportation for transportation to their medical appointments, including behavioral health visits.

We're thinking about the role of Medicaid administrative activities claiming in terms of transportation. And certainly, you know, these connections between the managed care plans and our correctional facility partners will help to facilitate facilitate that, I think to the point that Dr.

Liu was making about kind of the time frame for getting folks enrolled in our Medi Cal managed care plans. We have implemented, starting in October, new processes to help facilitate the assignment of Medi Cal Members to a Medi Cal managed care plan when the pre release services period begins. So the correctional facility.

It's all very nuanced, but they basically activate the Member in our system, which triggers on the back end the assignment of the Member to a Medi Cal managed care plan. We're looking at data based on information that we've received from Yuba County, Santa Clara County and Inyo about kind of how that's working or not working.

So we're looking at data to see like if there are any breakdowns in the system. But we have put into place system changes to allow for those assignments to be made while an individual is still in custody.

Of course, in county jails, in particular for adult jails, you know, a majority of people are in and out of jails in a very brief period of time in less than a week, which makes that assignment to a managed care plan difficult to achieve within that time frame.

But if our correctional facility partners are getting folks who are not previously enrolled in Medi Cal signed up for Medi Cal, then that will help expedite those processes post release. And we've also allowed for. I'll have you wrap up with this thought right here. Okay.

We're also allowing for our community based providers to Bill fee for service in that post release period for the care management services for up to 30 days to make sure that that transition to managed care is happening and that the ECM providers can still get reimbursed for services. And I'll stop. Thank you so much.

A lot of great information. We'll open it up to our colleagues first for any questions. I see Senator Richardson is going to take us off here.

Thank you, Madam Chair. My first question had to do with. With the. According to my notes, you had an enrollment of 126,000 medical enrollees receiving the ECM program or service out of 14.89 million enrollees. Am I safe to assume that the reason is so Low because you just launched the program, or is that an accurate question?

So that's the enhanced care management benefit at large and not necessarily specific to the justice involved population of focus for enhanced care management.

Okay, then my second question would be who are the typical individuals that would have access to this program? Meaning in my community, unfortunately, we're seeing quite a few people who might have mental health issues that are unfortunately around arrested who really need mental health treatment.

To be honest, I have not gone to one of the facilities, so I'm not really familiar. But I would imagine if someone had mental health difficulties is then incarcerated. What you were talking about some of the Shorter terms that people are in and then they're just going back out. What are the typical individuals?

Is it someone like that who might be unhoused and has mental difficulties, or is this a person who's typically committing other crimes and happens to also have a mental difficulty?

Maybe. I'll start with criteria, and then you can talk about how you apply it. So in the special terms and conditions of our waiver that we negotiated with the Federal Government, it lays out the access criteria for who is eligible to participate in this pre release services program.

All youth under the age of 21 or under the age of 26, if former foster youth are eligible, if they are Medi Cal or CHIP eligible. So there's no additional access criteria for youth in any facility, whether it's the adult facilities or youth facilities for adults.

However, there are specific criteria around access, including that the individual is medi Cal or CHIP eligible, that they have an identified condition, including mental illness or substance use disorder, a significant clinical or chronic condition, traumatic brain injury or idd, HIV or aids, pregnant or postpartum. And I'm probably forgetting one.

But the idea is that the most acute populations would get access if they are medi Cal eligible and they have a significant or clinical chronic condition, then they'd be eligible if they meet one of these criteria.

So my last question would be, if a person is then ready for dismissal or release, who determines if a person's qualified? Is it because they have Medi Cal and they're given the option, hey, do you think you need these services or are you looking at their prior history to say, zero, this person, you know, had this particular diagnosis and needs this care? How is it determined who's selected? And thank you for your patience, Madam Chair, as I'm relatively new to this subject.

If I may, I'll speak to that as one of the counties that's gone live. So we'll share with you some specific examples. So our average daily population in Yuba county jail is 350 to 380. Nearly 90% will walk in the door, Medi Cal eligible or Medi Cal enrolled.

So the kind of delta for us to even need to process Medi Cal Education, thankfully, is really small. And then we actually have embedded public assistance and public health staff to work on changing that into what's called a justice involved aid code.

And with that aid code, clinical services and reentry care services can be billable through the Medi Cal fee for service system. And just to let you know, all of them will qualify under the MED medical indication because it's a long list like Autumn just listed out like six.

It's probably about a good 30, including obesity, including a history of hepatitis B or C, a history of syphilis. So we have not seen someone who hasn't qualified as long as they have Medi Cal and we can confirm that they have a Medi Cal Sin number, CIN number. We input that in, we activate the JIAD code.

And in Yuba county, this we recognize, that was just like a healthcare model. Hospital discharge planning is now like reentry care coordination.

So we all just gather together in one small team called multidisciplinary team Discussion Monday through Thursday for one hour adult probation, our jail medical contractor provider, Wellpath Behavioral Health, our jail project manager for County of justice wealth, me and our in reach provider.

We expect everybody to sit at a table and talk about every, every single inmate or Juvenile Detainee who qualifies and has a JIA code activated. Medical, behavioral health needs, Social Determinants Health needs. And then the jail gets to tell us when is the release date because they will know that information from the court system.

So then we plan it out so we'll activate it within say two days after they're booked into the jail, they go to court and the court says, okay, Mr. Judson is going to be released April 15th. Then we know that's our timeline to work on the care coordination.

And then once the inreach provider gets to contact and Mr. Jetson agrees to talk to them, sometimes Mr. Jetson doesn't want to talk to us or the inreach provider. Then we give them the health risk assessment and give them the reentry care plan. Because they need to know what we are doing for them. Right. Because we need their buy in.

Thank you, Senator. I appreciate your questions. Because that means that more Members are understanding what's going on in our communities. These are millions of dollars coming down to every single county. And if we really use them the way they were intended for, this is instrumental for our constituents. Mr. Co Chair.

Thank you, Madam Chair. I hear the concerns about one time funding. There's a need for sort of ongoing funding, addressing reimbursement rates to ensure that we have adequate staffing ratios. So one of my questions to you was what was what could the state do to help ensure the successful implementation of this initiative?

So I think you've kind of answered some of that. But I do have a question around sort of the transition between prison to probation. So to Ms. Fuchs, thank you for being here today.

What are the challenges that you anticipate your Department will face in facilitating access to health care and other services for the populations that you supervise as that transition goes from leaving prison, whether state prison or county jail, to probation and release.

Sure. Thank you for that question. I think where we continue to struggle is our understanding. We're probation. We don't do medi Cal billing. And so at least in our county, there's a lot of confusion as to how this applies to probation still. And so we keep trying to say this.

We're involved in this, and how can we work together as a county? So it's taken us until this month to put together a steering Committee. So I would suggest you unplug your phone because you're going to get a lot of phone calls from 55 other probation departments, because that sounds amazing. And so we.

We are finally now getting all of our partners that were all stretched in other areas. Everybody agrees that this is a great initiative. Everybody wants this to work. And so there's no resistance to it. It's trying to wrap our heads around it. And so we have.

We deal with youth in custody, so that's one big mountain to overcome. And then we have clients that are in county jails, clients that are transitioning out of CDCR. How do we tie into that transition? So that's what we're still working through. And so up until this point, it's been very siloed.

And so it's kind of been every Department trying to figure it out on their own. It took me until about four months ago to apply for pathfinding because I couldn't quite understand what it was for, because this is work we already do.

And so trying to get our staff on board with, no, we need to apply this, and here's why. And there have been great workshops out there, but it's really challenging for probation staff to sit on a workshop that is provided by medical folks. It's just a different language.

And so we finally are getting to the point where we're convincing our staff, yes, we do this, but now we can get paid to do this. But making that leap and that transition to medi Cal billing is what we're really struggling to work through.

And I had breakfast this morning with several other chiefs that are all kind of in the similar phase of. This is the first I'm hearing four have launched, four counties have launched. So that's great. So there's some areas that we can learn, but we all are going to be doing this very differently.

And if you're from a small county, it looks different than if you're a medium sized county, it looks very different. And if you're from a large county. So that's where we continue to struggle. I'm not sure if that answered your question.

I made Another question to Ms. Heinz. So many of the individuals being released from state prison will once again be supervised by county probation departments. So could you maybe elaborate on the efforts being taken or is the Department planning to take on the coordination with county probation departments to facilitate that handoff?

Yes. So thank you for the question. We, we just recently spoke with Karen Pink, knowing that the probation chiefs are looking to identify how they can fold into our current process. Accurate. 50% of the population releases to probation, 50% to parole. We're looking at identifying the person's enhanced care manager. We exchange documentation now with probation and parole.

So we're looking at developing a technological system where we can identify the person's enhanced care manager and share some of the reentry case planning components under the appropriate data sharing agreements for the population leaving.

And we also agree that the enhanced care managers need extensive training to understand the criminogenic factors that both probation and parole will support once they transition to the community. We see Calaim as that necessary stopgap for supportive services that will only bolster what we do both in parole and probation. And my background is parole.

So for 20 years it's been a gap that we've seen. Many of us have worked together for a long time and just have not had that safety net for the population. So where they may come out with some stability, they immediately decompensate within two weeks. They do leave us with medication in hand.

Often they will, you know, if they don't have these supportive services enhanced care manager and their probation and parole officer on board, they'll sell that for a Happy Meal or transfer and they'll be lost. So this is again, I'm very optimistic about this. It's something we've been asking for for years.

And I'm just really happy of the support that we'll get from dhcs in this initiative.

Madam Chair, in closing, first of all, thank you for inviting us to participate in this portion of the hearing and say how excited I am that this initiative is launched. The more we can remove barriers for people reentering out of our criminal justice system is absolutely critical. Critical whether it's housing, whether it's employment, whether it's health care. It's absolutely critical to.

Making sure that people are supported, have the resources and do not reoffend and end up back in the criminal justice system. I hear several things. You know, funding, ongoing need for funding, making sure that we can adequately provide reimbursement so we can have adequate staffing ratios, data sharing, coordination.

These are things I think we'll have to focus on as this rolls out and hopefully something that could be a sustained long term effort. So thank you.

Thank you Co chair and I have several questions. Okay, I'll start with the Director, maybe Deputy Director here. You responded to the one time funding as an investment infrastructure.

Is it safe to assume that that's the case because you are now getting paid for services that you were already doing and that offsets and you can utilize that funding for further investment? Was that the concept? Okay, but I saw you shake your head. Why does that not play out that way?

I don't think that the fee for service rate will be able to cover the full staff and comprehensive programmatic development that's needed. I mean I'm a health officer and I spend at least five hours per week on this like and this is not within my scope. And that's just one staff. Right.

And when we talked about the multidisciplinary team, that's probation, that's behavioral health, that's our well pass contractor provider. We even had to transfer over a project manager and her full time job is to do calium justice involved for the jail and the detention center.

We are currently covering that superb project manager's time with public health grant funding because we were unsure of how it would play out. And so that's the concern and even more so in terms of our staffing funding is the inreach provider reentry care bundles, there's five bundles is fairly Low especially compared to the ECM rates.

And we're always afraid that our inreach provider will say you know what, we can't sustain this model and we're going to have to have you find something else and we can't do it and they have the expertise that we don't.

Thank you Chief. You mentioned one of the barriers was the data hipaa. You mentioned hipaa Director of OSS or maybe Deputy Director. What can you tell me about HIPAA being a roadblock to data sharing?

I will say that under CALAIM as part of AB 133, our Department has put out extensive CALAIM data sharing guidance that we have shared broadly with our correctional facility partners.

We also put out this fall for public comment a reentry data sharing toolkit that specifically aims to demystify HIPAA and 42 CFR Part 2 for Substance Use disorder data sharing. So it gives some tips and information to our correctional facility partners to help facilitate the data sharing process.

As part of the requirements there is a release of information required which if signed by the Medi-Cal Member, would enable data sharing across these multidisciplinary teams, would enable data sharing with the community based providers who are doing the post release reentry.

And we are looking to have conversations about expanding a universal consent for data sharing tool through that we piloted previously in the Medi Cal program as part of AB133 into this space to make it even easier for our correctional facility partners to make sure that all of the appropriate consents are collected for sharing with all of the various partners.

But we have put out extensive guidance to really help our correctional facility partners, community based organizations and other partners in the delivery system understand HIPAA and understand the limitations, including Those under the 42 CFR Part 2. Thank you.

I was just going to add this is again kind of these new systems talking to each other and having that comfort like zero, that allows us. Are we sure? It allows us and county councils having differing opinions. And so we've tried to put out guidance from our perspective that this is allowed. AB 133 provided that in statute as well. But it is these conversations I think that as folks get comfortable at the local level as well

Directly from the source. One other question I'll turn over to my health advisor over here. Vitka, I'd like to hear from you. How can we ensure when CBOs, who are the ones contracted to provide the ECM and so forth, are getting the necessary amount of referrals to make the cost worth it to continue those services?

That is the essential question, really. That's the big issue. So.

So you're going to return that question to me, is what you're saying?

No, no, no, I'm not going to return it. I'm going to say perhaps it's just in the initial implementation of the ECM benefit that you see managed care plans contracting with huge networks of ECM providers. So as an entity that provides ECM services, we really can't.

We met with many plans to talk about and we have lots of years of experience again working with corrections population or CJ population and they could never say how many people they thought they would give you because maybe they had 506070 providers. You can't build a program around that.

And so Perhaps it's in the process of kind of like this is their first run and then winnowing it down where they begin to look at specialized provider networks. It's a recommendation honestly on the plan side to the mcps that they look at specialized providers. Because again, you can't build a program around.

I'm going to get one person a month, three people a month. Like how do we make sure that we can do the billing and have sufficient staffing to do the care coordination? Some people are very high need folks and some people have lower needs.

We've tried to urge the plans to consider kind of more of a per Member per month. The way that managed care plans typically often operate is you get assigned a group of Members and then you deliver the services as needed. Some people need a ton of services. You're seeing them multiple times a week.

Some people need a pretty light touch, they're leaving pretty stable. But it lets the entity, if they have sufficient mass to be able to manage that to deliver the care.

And so over time we're hoping that the managed care plans begin to see there's value in either specialized ECM providers and also just kind of narrowing that network a little bit.

Thank you. Recently in my district I was able to tour an Adelanto county jail facility to witness some of their re entry programs and services. And it was a very, very enlightening experience. I'm sure all of you here have had that experience at 1.0 or another.

In my conversations though with the deputies, one of their, the hardest parts of their jobs are ensuring the safety of the personnel who are non jail personnel there to service the inmates, which is historically why they've been resistant to support reentry initiatives. Because of those safety concerns. Do we currently have the buy in from our local sheriffs?

Is there additional supports that they may need to be more successful specifically when it comes to the justice involved reentry initiative?

So if I may. Thank you for that question. I have tremendous buy in for my sheriff, but it's only because we're currently utilizing past justice involved funding to hire three new correctional deputies full time. That's all they do. They ensure the safety of our behavioral health staff. Who's coming in, our in reach staff, our project manager.

You are right. That was actually one of the first question the jail commander under sheriff and sheriff asked me. They're like, Dr. Liu, I cannot have a safety incident, not one. And I said okay, how can we make that happen? And he's like, okay, I, I will agree with you, but you need to find me the funding.

And so when PATH just involved came, I'm like here's the funding. But I'm here to tell you as honest. He keeps asking me, he's like, what's going to happen once the path doesn't fall, Funding runs out? Like, where are you going to find me new funding? And that's where I have trepidation about.

Is the fee for service claiming through clinical services that we currently provide going to be adequate to keep even those three correctional full time deputies?

And then my next and final question is so how does the justice involved reentry initiative apply to our undocumented incarcerated individuals and does participation in the program affect any federal processes related to their release?

And I'm not sure if this is a Department of Health Health Services can weigh in on this or the just in terms of Medi Cal, undocumented persons are covered as long as they meet income. You know, the other eligibility requirements. And so I would defer to corrections in terms of any. Yeah, okay.

We don't ask them their documentation status. We actually translate out flyers in multiple languages. So our dominant other languages besides English are Spanish and Hmong. And so we have a flyer that we basically say this. We can't talk to you about your essentially criminal case. Like that's all you and your counsel.

And we're not here to talk to you about your documented status. We're here to just take care of your health and your social services. So be just really honest with them. Yeah.

Did you want to add to that?

I was just going to say it's the same for us. Anybody that's Medi Cal eligible has an access criteria for their health or behavioral health needs, is processed the same way.

Okay, thank you so much. I have one final question. Chief, you also brought up that sometimes this kind of plan can impede the court ordered plan. Can you tell me a little bit more about where the barriers happen there? And then additionally when someone's being released, is there separation and explaining to the individual?

Okay, these are your court order services, but these are also additional services. You can participate so they don't feel like they have to do it all. And anyone else who wants to add after the change?

Yeah, no, it's a great question and I'd be happy to hear others answers because we're still working through that exact thing. So we as probation are responsible for enforcing court orders. Those all get explained. The conditions of the terms of probation get Explained.

So now you're layering in additional more complex work and how probation fits in, whether they're coming out of the jail or they're coming out of prison. Where is our voice at the table? How do we inherit that plan and then how do we implement it? And so that's where we're still struggling.

We haven't seen it, we haven't gone live with it. So we're still struggling to kind of understand how that's going to work.

So how we try. Sorry. So how we try to ensure that prevention of duplication of services and not to confuse these vulnerable population who are dealing with a lot already, is that we actually request adult services.

Probation goes along side of behavioral health and our inreach provider. So it's not just three different people talking to this inmate. They have to go together. And then at the end we talk about them again and we say, okay, who's responsible for what? And we clearly lay that out. Okay.

Post release probation, you're responsible for following up and making sure they show up to residential treatment. But guess what? In reach, they need transportation to get there. Probation can't provide it. You can drive them because they're not yet on medi Cal Managed care and then behavioral health, when they're released back from residential treatment, they have severe schizophrenia.

You need to make sure that they have an appointment with county behavioral health. So it does require a lot of coordination. And the jail project manager essentially is the conductor and then I am the secondary conductor. Instead of. She gets stuck. She doesn't have the clinical knowledge. She.

She consults me to see how do we navigate for every single JI involved.

Person, one voice altogether, providing the plan together and not confusing the individual. Yeah. Okay. Senator Rubio.

Sorry. I wanted to discuss a little bit survivors of domestic violence and some of the programs that you have in place. First of all, I know that there's a lot of trauma and, and sometimes it's not diagnosed until years later, such as PTSD and things that victims have to deal with.

So what programs are in place to capture those traumas as they're coming out and how do you connect them with services, whether it's housing or services? I'm thinking in terms of having to be released into possibly a dangerous situation with an abuser. Can you share a little bit of the program that are in place? Thank you.

Yeah. We're really fortunate because we're small, so everybody knows everybody. So before we even implemented went Live. We kind of did a roadshow. So we presented to the judges, the DA, the public defender, our local CBO's, our homeless consortium, so they know that we're going live.

And one of our critical partner is a domestic violence shelter organization called Casa De Esperanza. And she actually already had a program Casa in the Yuba County Jail to work with victims of domestic violence. And then when she knew that we went live, she actually reached out and requested a meeting.

So now it is my expectation that the CALAIM project manager makes sure that she is involved for any inmate who has a history self report of domestic violence. So that again, we're speaking with one voice and the left hand and the right hand know what each other's doing for safety.

Well, just to touch on that, I know that, that you, I think you just said self identified victim or someone that you know, but is there, I suppose training on how to identify those that don't just self disclose or talk about their trauma? I know that it'll manifest itself in many other ways. Sometimes it's behavior, right.

They can get in trouble while they're inmates. But is there any other way besides self identifying or having that history on record that you can identify what's happening within that person?

Yeah, we usually rely on our correctional deputies to raise concern, our wellpath directed contracted jail medical provider. But then when the behavioral health counselor comes and interviews them and they send something, we'll bring that back and then we will share kind of notes and we're like, you know what, I think we need to unpack this a little bit more. Who's going to take the point to talk to that inmate? Thank you for sharing.

Of course I lied. I have one more question. Typical Senator Medjivar. So someone brought up the barriers for the you are discharged from a county, but you have to be released to the County of your origin. And there were some barriers to that.

And I'd wanted to hear what can we do to streamline that or what the Department is also doing is have you heard this concern before and how are we addressing that?

So there are opportunities and we are availing the population the information that if they have supportive services or family in another county prior to release, at least for CDCR, they are allowed to identify that location and be transferred into a different county. Now I'm going to say that. But the issue sometimes is our barriers.

If we had one that we'd want to talk about a little bit more is the ability to change. If we've already started our process at 135 days prior to release to get them enrolled in Medicare or Medi Cal and then they transfer to a different county. That process is very arduous.

So that's where we really see the gap. It's not at all points in times, at least for parole and CDCR if they choose to go to a better county that fits their supportive services and their family relations. But opposed to do we have enough time to transfer the Medi Cal benefits between counties.

And if you don't mind, I'll just add that we did put out guidance specifically for the justice involved initiative around intercounty transfers to help facilitate transfer of Medi Cal as people move from county to county post release. So I think, you know, nothing's perfect yet. We're working on it.

But we did put out guidance to try to address that specifically.

If I could just add the challenge there actually doesn't lie the intercounty transfer of Medi California actually lie with dhcs. It's the complexity between county based social service departments that actually do the enrollment and it is. That is highly problematic.

It is a burdensome process that takes way too long and people get lost in the process of that.

Is it a lack of data exchange or what's the biggest.

It's a different Department. So it's the social service departments like picking up the phone or like get. I'm sorry, but it's true, right? It's just. It's getting the actual information responding to the. Whatever county is requesting the transfer. This is a long standing problem that's outside of just, you know, which we.

I've talked about with my friends at DHCS. It doesn't actually live there. It lives with the entire benefit enrollment process which again is handled at the social service Department level, not at the county like health officer level.

To be fair to my social services colleagues, how we try to solve this because we've gone live is I just educate them. I just be like, you are a really critical part. Without you, nothing happens. Because without Medi Cal status, there's no. Aid code

Unbiased as a social worker. That's very, very true.

Thank you. So it does require a lot of education and then it also requires a lot of follow up. So this project manager of mine, she is amazing. Where I say, Stephanie, you need to make sure Mr. Jetson, who's going to be transferred from Yuba county, are those.

The employees that you mentioned that you hired just specifically for Cal? Yes, ma'am. And that's what makes it a little bit Easier for you because you have specific employees for that.

Yes. Yes. Yeah. This is her entire job. I was like, Stephanie, you need to make sure Mr. Jetson, who's transferred from Yuba to Humboldt County, everything is seamless. Everything's seamless. Medi Cal doesn't get dropped. Anything gets dropped. And then it's within the partnership service area. So we're lucky that.

But we've also encountered transfer to Sacramento, just our neighbor to the south. We have literally just called them. Like, I would just call the probation Department and be like, hey, I'm really worried about this person. Please have a really warm handoff. And they get taken aback a little bit because they're like, wow, the health officer is calling.

But. But I was like, I'm very invested in the success of this person.

All right, Doctor, we will need to clone you. And then. So everyone's changing their mind up here. We have another question.

Well, you are the leader, and you set the tone, so. Touche, Senator. Thank you. I'm sorry. I just want to go back to it, because I'm always looking for ways to support the system where it needs to. Right. And right now when I post the question. So I guess it could be to you, since you.

You answered it. And we talked about programs for these domestic violence. And I know, based on my research, that there's a really high correlation between victims of domestic violence and homelessness.

And I know you talk so highly of the program and going live and what you do, but is there areas of concern that you see, based on your knowledge, in areas where we can support in a much bigger way to ensure that these victims don't end up on the street or going back to their abusers?

And so sometimes, again, based on my research, they don't even know they have PTSD or they're suffering from some type of trauma. So can you share anything that we can do to strengthen services or help in that respect?

I think my only recommendation that comes to mind is we have to kind of look at the vulnerability index. So when someone raises their hand and say, I'm homeless. In coordinated entry, there's a system to determine their vulnerability, and that really kind of dictates the priority of placement into housing.

So is there a way to look at essentially, the weighted score from a history of ptsd, even if they have not, as of yet identified as a victim of domestic violence? So that could be one thing.

So we actually do require in reach provider to already input every single incarcerated person while they're in custody into the local homeless management Information system, hmis. But we don't get to decide that all those individuals immediately get prioritized for placement and housing. Right.

Because there's all these other individuals outside of the in a carceral setting that also are coming into coordinated entry. So it's a tug of war kind of thing to kind of say like who do we prioritize? And these are heartbreaking choices because what if it's like a homeless family, what if it's a recent refugee family?

Thank you for your thoughts.

I want to thank the panelists for this robust conversation. What I do appreciate the most is that people are hearing things that perhaps they hadn't heard before, bringing back ideas from other counties. Dr. You're phenomenal. I think Sonoma is doing a great job. I'm excited to see all the other counties come and join on this.

I do have concerns, LA, of course, LA probations, I do have concerns and how that's going to be implemented in LA. But we'll have that conversation down the line and the Department here took wonderful notes to ensure we continue to streamline for a justice involved individual. Thank you so much.

We're now going to turn to our hands care management and community support conversation. So ECM is what provides the care management to the medi Cal enrollees. It's the one stop hub that connects you to your services.

People who are facing homelessness, people with serious mental health or substance use disorders disorder, adults of risk of long term care institutionalization or people transitioning from incarceration. Like we just heard, it focuses on individuals who are pregnant or kids in the foster care system.

ECM as you will come to hear, gives these individuals a lead care manager to coordinate all of their healthcare and help them link to the social services.

So today we're going to be hearing from Linda Way, the associate Director of Policy advocacy at Western center on Law and Poverty and Hugar Dickman, the Director of California Long Term Services and supports advocacy justice in Aging. This does have. You can stay here. It's totally fine. The second part of the panelists are the providers.

So you can say that's totally fine. It's okay. It's all right. It's all right. Because it's two parts but it's the same panel. And then we'll be hearing from the providers. The ECM connects them, the individuals to the providers. It's the CEO from Caress Ceres Community Project. zero, I thought you were these people. Maybe not.

Maybe I'll stop here. Okay, we'll come back. We'll start with Linda.

Good afternoon. Linda Nguy with Western center on Law and Poverty Enhanced care management and community supports can be life changing for Medi Cal Members who are able to successfully access coordinated care that addresses the whole person's need through coordination of housing, meals and personal care.

However, Medi Cal Members report challenges accessing both ECM and community supports, although utilization for both has still steadily increase. Less than 1% of Medi Cal Members have received ECM or community support since implementation in 2022.

Advocates report improvements in processing timelines for both, although it can still take months to be approved and reauthorized for those who need services for longer. At the same time, there's quality of care concerns.

Some clients with ECM are unaware of who their ECM provider is assigned that the anticipated level of meaningful engagement in this intense and supposedly in person service is not consistently happening. Clients also report that their ECM provider is not trained to provide the intended service.

Coordinating care among different providers we appreciate that the Department is seeking to increase standardization for community supports, but our advocates still report plans, narrow eligibility criteria, or impose additional limits. For instance, we have clients who request housing deposits but are told that they must first request and receive housing navigation services.

Once they've gone through that process and their housing deposits are approved, the housing unit is often no longer available. Despite raising this to the Department last April.

This narrow eligibility criteria remains in place and is not expected to be prohibited until later in July, 15 months after this was first raised, leading to questions of oversight and accountability for a program that the state has invested significantly in.

We also heard of some housing providers just not providing housing deposit because of difficulties getting reimbursed, including time it takes to receive reimbursement. Our advocates report it can take one to two months following approval for providers to receive payment for housing deposits.

Few if any landlords are willing to wait months to be paid this one time deposit, raising questions of how transitional rent rollout will actually look like. The Department has shared its goal to make all community supports a statewide Medi Cal Benefit, with housing support services and medically tailored supportive food being the farthest along.

We recommend the state seek federal approval to make these services a benefit to draw down federal funds and truly standardize the benefit. Housing support services have been shown to improve health outcomes and reduce costly acute care, particularly among those who are homeless, and particularly important considering the rise of homelessness and those experiencing homelessness with a disability.

In addition, other red and blue states have already made housing support services a benefit. Finally, we recommend the Department articulate specific, measurable targets define a mechanism to hold plans accountable and publicly report on progress toward targets rather than just focus on utilization numbers. There should be some outcome measures.

For instance, how many Members can access permanent housing and remain stably housed after receiving housing support services services.

We appreciate the quarterly implementation reports the Department provides, but recommend this data be disaggregated by populations of focus, provider demographic information, which is a factor in Member outreach and utilization and other accountability measures, including how frequently a person receives enhanced care management, which again is meant to be high touch and in person, or how long it takes a person to actually receive services from the date of service and the date of approval, as well as the number of people approved for services compared to those who actually receive services. Thank you.

Thank you so much.

Good afternoon, Madam Chair and Members of the Senate Health Committee. I'm Hagar Dickman, Director of California LTSS Advocacy for Justice in Aging. Justice in Aging has been an active stakeholder in the development and the rollout of enhanced case management and community support programs.

We share the same goals as DHCs with respect to these new CALAIM programs improving health outcomes by addressing social determinants of health, improving healthcare access through coordinated and streamlined system, and reducing reliance on hospital and other institutional services through care management and preventative support services.

Unfortunately, three years into implementation, CALAIM services have been plagued with Low utilization rates, particularly those services targeted towards older adults focusing on enhanced care management First, ECM is supposed to be a statewide benefit for identified populations with complex needs that provides comprehensive care management, care coordination, and service navigation.

Care management could provide critical support for older adults who experience a severe health event and require additional supports after hospitalization or nursing facility stay.

Yet this has not come to fruition due to three factors.1 Data shows that health plans have had varying success in implementation, particularly in their ability to identify Members who would qualify for ECM and enrolling them into the service.

Two, DHCS data also shows varying levels of utilization among the populations of focus, and advocates and providers report inconsistent referrals due to an ambiguous referral process and 3 there is a General lack of awareness by medi Cal Members of ECM services and how to access them. Access issues are even more prevalent across community supports.

DHCS has provided plans with a menu of 14 of these optional services they may provide their Members. But because community supports are optional, inconsistency across managed care plans has led to confusion and Members and their advocates struggle to identify what services are available for a particular Member and how to access them through different plans.

Even within single county, there is Also, wide variation on utilization between different community supports. For instance, over the last 12 months of DHCS reporting period, from July 23 to 24, medically tailored meals served over 125,000 Members, while in the same period nursing home diversion to assisted living only served 765 Members. This is not for lack of need.

The diversion to assisted living community support service is nearly identical to the Medi Cal Assisted Living Waiver, which currently has 7,700 individuals on its wait list. The Assisted living community support, if it were offered by all Medi Cal plans, could clear the assisted living waiver wait list.

The community support can also expand access to assisted living services beyond the waiver's current 15 county geographic reach. Yet this has not been the case. Instead, the waiver waitlist is growing even though people on the waiver wait list are already eligible for the assisted living community support.

To improve utilization for the community support, DHCs should give all ALW or waiver waitlisted individuals the option to enroll immediately into corresponding community support. They must also actively facilitate connecting people on the waitlist with their plans and require plans to fast track enrollment and placement of waitlisted individuals.

And assisted living community support, along with all other community supports, should be made mandatory for all plans as soon as possible in order to remove inconsistency and confusion across the state and across plans.

In closing, we support the ultimate goal of better serving Medi Cal Members through ECM and community supports, but Low utilization rates, especially for services targeted for the highest needs.

Members indicate that oversight is needed to determine how to ensure that California's innovative programs are not just a great idea on paper, but are actually accessed and used by all those who need them. Thank you.

Thank you so much. Just two quick follow ups. If we make the community supports mandatory for all MCPs, but some counties don't have those services, how would we address that or difficulty in finding a CBO to offer that service?

Yeah, I think that's a really good question. I think one of the sort of higher level things that need to happen is there have to be network adequacy requirements for home and community based services that require managed care plans to make those investments and enter into contracts with those CBOs.

So it's true that the CBOs might not be in every area of the state and those investments would be necessary.

But I think also, especially when we look at the assisted living waiver, DHCS just came out with a gap analysis and in that gap analysis it says specifically the state is contracted with only of existing residential care facilities for the elderly. So, you know, the providers are there, but they're not actually taking on medi Cal Members.

And so I think it's not just insufficiency of CBOs. It's not enough CBOs that are willing to participate in the program. And that's something that I think dhcs needs to look at. Really? Like, what is the reason? Are the rates too Low?

Are there barriers to entry that are too difficult for these services to engage with the plans? Okay, and then that's another.

Yeah, we'll get back to that. For the assisted living waiver, the wait list, the 700 and something, is it the Department that needs to provide the green light or the managed care plans?

So the Department holds the wait list so they know who's on that wait list, and the information from who's on that wait list needs to get to the plants. And so the Department has that information.

They need to facilitate that communication so that people on the wait list know, first of all that there's a service available and are connected with that service and so that they can receive it.

Autumn, would you mind joining us again or maybe someone else, Director, Boss, or.

Who's gatekeeping this list?

So we, we want everybody to be served. So it's not, I don't know that I would call it gatekeeping, but we are working on a mechanism to provide visibility of these Members to the managed care plans. It is a kind of a Member by Member list.

And so finding out, kind of making that connection to the appropriate managed care plan is something that we are working on. And Susan Phillip is our Deputy Director on this.

Hello everyone. Susan Phillips, Director for Healthcare Delivery Systems. And so we oversee the assisted living waiver program. And yes, there is a wait list and yes, we actually manage that list and have that list. We completely agree.

We do need to have basically visibility of our managed care plan side to who's on that list to facilitate that. So that is something that we are working on through developing a portal so that our plans can actually log in, see who's on that list.

We do need to work out issues because plans can't see people who are not their own Members. Right. Because it's a statewide list, we need to make sure we work through some of those operational issues. But we do think that's something that we can implement.

Deputy Director, do you have a timeline? Do we have any kind of sense when we can get all these Members.

When we can have this portal for data sharing? Yeah. So we just actually talked about this yesterday and we do think that we can execute this by Q2 of this year.

Okay.

A portal for managed care plans.

I heard it here. Okay. Do you mind if. I think there is a step that can happen before the portal is up and running, which is to simply inform people on that list of who their plan is and how to get onto the. How to contact their managed care plan to request the service. I think it's a preliminary sort of easy step that can be done.

And may I just say that we do. In our most recent Community Supports Policy Guide Service Definition release, which was just published a few weeks ago, we did specifically state how plans can contact dhcs. Also that was also something that perhaps wasn't clear, but we also made sure that that was clear. So that's also low hanging fruit that we're trying to implement.

If I'm on that list, I'm in the network, I'm getting connected, I'm working with the provider. Does that provider, can that provider see that I'm on this wait list or do I have to physically tell someone I'm on this wait list or do I know I'm on This wait list. Three questions. Do you want me to answer that?

I mean, I think from the consumer. I think the first thing is we should ask who the consumers are, who these people are. People on assisted living wait list. Does that consumer know?

Yeah, I think there are pretty high needs folks, usually with a high level of disability and are working with a family Member or another representative. So it's very difficult, I think to us to put that burden on the consumer. I think communicating through a formal notice will be helpful.

But I think a lot of people don't even know who their plan is and don't know how to contact their plan. So it is kind of a burden to put on a consumer to navigate.

Thank you. Well, it is, you know, when we're talking about right now, when you post the question, it was difficult for you guys to answer. I kind of baffled us to now putting the burden on, as you stated, on the consumer, especially when they have, you know, pretty high needs and they don't know how to navigate the system. It seems pretty complicated, but I'm just a little curious as to. To tracking these individuals.

I'm curious to know if we have a sense of the populations that are being left out at high numbers. Are they Spanish speakers maybe? I just want to know if there's a sense of who these people are and is there a disparity in terms of who's getting enrolled and who's not.

I don't know that we have the demographic breakdown of the folks that are actually waiting on the. The. The list. So that's something we can get back to you on.

What about ECM as a whole? Because we have the numbers who are on and who are eligible for ecm.

We have that, that type of breakdown. But for the ALW or the 700 people, I don't know that we have that broken out on the wait list.

Do you have the demographic breakdown for those who aren't connected and who are eligible to ECM? Who are eligible for ECM?

So we estimate 3 to 5% of the Medi Cal population would be eligible for ECM. This is kind of our what we estimated when we really embarked on Cal AIM and to date we're at about 2%. And so we feel like we're meeting them kind of the kind of getting towards that target.

Some of these ECM populations of focus have not been live for three years. We phased them in over time, just like community supports. Not all of these things went live January 2022. And so utilization for the different community supports or ECM.

Populations of focus will be kind of the trend as these kind of continue to roll out our managed care plans, our CBOs and providers gaining more experience. And so we don't have a breakout of who should be eligible and is not receiving. We kind of have rough estimates based on just population demographics. And I would also know people.

We have those target focus areas, populations, And of the 2%, what population are we serving the most?

We do have that. We post all of that on our website by county, by plan. I don't know if Paul, if you want to come up.

I'll turn back to Senator Rubio while we're looking for this.

Thank you. Well, along those lines, I mean it's really concerning when you hear just what was stated here, the low utilization rates. And I think one of you mentioned that it's oversight that we're needing. Right. It really is quite the task to put the burden on the. On the consumer. I'm just wondering.

You talked about the portal and how to better connect people and you said that you can't put the information out there because it. It's just everyone and the information cannot be given if it's not your own provider. But. And you said that you're going to get that up and running.

I'm just wondering, can it be a blind sort of portal where you just have. I'm trying to figure out how you expedite that, where you put the person and there's a way of safeguarding the information. So it's just not open to everyone. You do have a list of people, but how do we safeguard it? Can it be done faster?

So this is going back to the assisted living waiver list. So we have that information and it's really a matter of basically populating it with the individual CIN numbers, which is a customer information number, then connecting it with our managed care plan eligibility information and then cutting it by each managed care plan and then making sure each managed care plan that has that Member understands who they are.

So we need to essentially then make that available to the managed care plans whose Member, those individual Members are, which they belong to.

Thank you. And I have another question also. I know that it's already difficult to manage the system, but is there a requirement, requirements that perhaps eligibility requirements that perhaps unintentionally exclude people in your opinion? This is not asking your opinion. Are there things that we can remove in terms of the requirement to encourage more people?

I will just add for enhanced care management, we just rolled out policies starting from last year in 2024, to kind of almost presumptively make certain populations eligible for ECM or enhanced care management by population of focus. And so really trying to streamline and remove those barriers.

Those are new things that we've recently implemented that weren't live when we started. Kelly but just given the feedback that we've heard over the last couple years, given the concerns raised about some people should be automatically eligible.

So, for example, if a person has contact with a street medicine provider, they should automatically get ECM as a homeless kind of population of focus.

So we have a whole list and we're happy to share of some of this kind of what we call presumptive or authorized streamlined processes for certain populations of focus and the providers that serve them.

Thank you for sharing.

And I'll just add to that, that since the beginning of ECM, we've really opened up numerous avenues by which people can get connected. So anyone can refer to ECM, the Members can refer themselves. Their family Members or loved ones can refer them. Their providers can refer them. Schools, counties, social services.

We do know that sort of being aware of the referral processes and how to refer has been onerous. So we also rolled out just this past summer streamlined referral processes that have a standardized form statewide now, because before, each plan had sort of its own process, which is very challenging, especially for counties where there's multiple plans operating.

So all of that has gone live now as of January for a much more streamlined process. And to go back to the earlier question, zero, and sorry, I should have introduced myself. I'm Palav Babaria. I'm DHC Chief Quality and Medical Officer and Deputy Director for Quality and Population Health Management. And my team oversees the ECM benefit.

To go back to the earlier question about disparities from our quarterly public reporting data, we do do breakdowns by race and ethnicity and by language and by age. We have seen some persistent trends since the beginning. So, for example, English speakers are overrepresented in our ECM population compared to native Spanish speakers in aggregate at the state level.

One of the challenges and similarly, the race and ethnicity sort of don't match up our race and ethnicity breakdowns in aggregate across the state. One of the challenges is that we know who's eligible for ECM is not sort of reflect the statewide population.

So if you look at our JI population, if you're incarcerated, you are more likely to be black or brown. And so the sort of race and ethnicity breakdown doesn't look the same. Same thing with language.

And so what we are Trying to do is get more precise on who's eligible because then we'll be able to see is there a disparity between who's eligible and actually getting the service. For some of the populations of focus, the eligibility is really clear. Like child welfare, we have aid codes for foster youth.

We can pull it up. We have race and ethnicity and language information and we can see if there's a disparity for some of the populations of focus, like families or individuals experiencing homelessness.

We don't actually in current state have good data on who's experiencing homelessness in Medi Cal unless someone puts in a billing code and that comes through. But that doesn't happen all the time. So for some of our populations, you have to ask someone, are you experiencing homelessness? That's not something that's just in the data system.

Through other initiatives like BHT and Prop 1, we are working on getting those data sources so that we can really drill down on this. But that's some of the limitations today.

Thank you. One last question. And now you know why you're the professionals, right? Because we have to dig through a lot of information. And I'm just. When I try to frame it as a teacher, I just remember, let's say having a child with a lot of needs and the way we would make sure that they were successful in the future is you have a cum or something that follows that child where you're trying to keep track of everything that you've.

All the services you provided and you know how to move on to the next step and get the other person to provide the services. I'm just wondering, like in your territory, you know, we know that some people suffer from mental health homelessness and they may go from provider to provider.

Is there a system where everything is connected and they talk to one another and they know where the person's been, where they're coming from so the next person can pick up where they left off. And I don't know. So I'm turning to you to see if there's a system for better communication.

I think the short answer is no. And that is why we have so much fragmentation across the state. We are working to break down those silos. So there's a number of initiatives at the state level of how do we break down our data silos even between, for example, Department of Healthcare Services and Department of Social Services.

So we know who's serving each other across our two departments. But those same silos exist at the local level.

So I'm also a practicing primary care Doctor And I will tell you in my clinic every week when I go, I don't know necessarily what the specialist is doing if that specialist is not in my health care system or what happens outside of the four walls of our clinic.

And I think efforts like the data exchange framework for our state which are really helping to build that information sharing not just within health care where there are lots of deep silos but more importantly with health care and social services is really critical to get to that sort of longitudinal care plan that you're talking about.

Thank you. So what I consistently hear from providers in my district and hospitals is that they're in financial duress. Reimbursement rates make it nearly impossible to balance their budgets. They're constantly having to look at cutting services because they're struggling. And hospitals particularly in our rural areas are in financial duress. So is this impacting the success of our community supports and ECM initiatives.

I would just generally say hospitals aren't generally enhanced care management or community support providers. There are some instances for children in kind of the with specialty care needs who might be enhanced care managers. But, yes, all of these things are linked together.

There's been kind of a whole other portfolio of work done in the hospital space related to directed payments and trying to increase revenue to our hospitals and think about how we can support them unrelated to the initiatives we're speaking about today. But, there are tons of puzzle pieces that really go to support the entire delivery system.

So, then you would say no, that their duress is impacting the success of these programs?

I mean, the entire delivery system is all part of these programs. But in terms of specifically community supports hospitals as providers or hospitals as ECM providers, they don't participate as much in these two particular initiatives. If you have anything more to add.

Yeah, I think that's a fair statement that sort of the success of ECM and community supports is not contingent on the hospitals.

That being said, for some of the populations of focus, and we'll get to this in the ECM portion, you know, we want to meet members where they're at, and for each population of focus, where they go, and who they have that trusted relationship with looks wildly different.

You know, if you're a CCS kid, that's going to look different than if you are in child welfare, or if you're an adult who's in and out of the emergency room every single month.

And so, especially for the populations of focus that qualify because of repeated emergency room visits or hospitalizations or some of the complex populations served in hospitals like CCS, we know our hospital partners are probably the best position to provide ECM services. And they've been sort of under-participating generally for a variety of factors.

And so, you know, I just gave a kickoff last week at an academy that's been funded outside of DHCS to sort of help support hospitals to really take advantage of CalAIM and ECM because that could be a sustainable revenue source for them if they're able to set up their program and participate.

And then to kind of address the, I guess, I'm going to call it the elephant in the room; there has been a lot of discussion currently in Washington D.C. regarding Medicaid funding, and does DHCS have a contingency plan for the three initiatives being discussed today? Should we see the event of federal funding for Medi-Cal California reduced or cut?

So, I'm just going to start by saying we remain committed to everything we've talked about today, and I do not want to lift our foot off the gas pedal. We see such value and such really improvements in health and well-being for our members as a result of these initiatives and don't want to stop.

And so, you know, notwithstanding the conversations at the federal level, depending on what comes forward, I mean, we will have to address the impacts to the Medi-Cal program. But we do want to be very clear. We're committed to CalAIM and we're committed to BH-Connect. We want to do this work--don't want to have any of this work pause because we're of the uncertainty today.

And do we--is there an estimate of what would need to be covered? Are any of those numbers being covered?

We don't have any numbers to share.

Thank you.

Perfect segue into hearing from the providers point of view. I think we're missing two more providers. You're gonna be going back and forth. Might as well just stick around. Who's Cathryn? Cathryn, we're gonna kick off with you.

Thank you so much for this really important conversation this afternoon, and everything leading up, I think is going to be very consistent with my remarks. So, my name's Cathryn Couch, I'm the CEO for Ceres Community Project.

We're a community food and nutrition nonprofit serving the North Bay for the past 18 years. We've been contracted with Partnership Health Plan since January of 2022 to provide these services. And to date--so, we provide medically tailored meals, medically tailored groceries, nutrition consults, one of the community support services.

To date, we've served 168,000 meals to about 1,000 Medi-Cal members. And it is still a fraction of the eligible population in the four counties we serve. So we serve Sonoma, Marin, Napa and Solano counties.

98% of our referrals have been self-generated through long standing healthcare relationships in our community, with fewer than a dozen coming directly from the managed care plan. Community providers like Ceres are embedded in the social and healthcare ecosystem in our communities. We are known and trusted, something that's really important right now.

And we work collaboratively to serve hard-to-reach populations like those who are unstably housed, dealing with mental health or substance abuse or from immigrant backgrounds. So, Ceres partners with multiple housing and behavioral health providers to reach and serve these members.

A recent analysis of contracting for community supports and enhanced care management conducted by Eviset, a data analytics company, indicates that 70% of all funding for these two parts of CalAIM, an estimated 858 million annually, is going to for-profit organizations who are often not based in the communities they serve, and 14% of funding is going to organizations outside of California.

Without a shift, my concern is that this will lead to a significant disinvestment in the safety net providers in our community who provide many services beyond caring for Medi-Cal members. In addition, directing these dollars to community providers will deliver higher quality services, improved health equity and overall greater value.

Community providers are more likely to identify and reach members who can most benefit from these services. Plans in the department often refer to network adequacy when plans have contracted with a lot of providers.

But if you're only contracting with for-profit providers who are not embedded in the social and healthcare ecosystem, you are likely to miss members who most need these services. Community providers are more likely to provide care that is trusted, layered, longer term and culturally competent. And finally, community providers lead to layers of value for our communities.

We create jobs and economic value, strengthen social cohesion through volunteer engagement and lead to ripples of positive benefit. Ceres engages more than 700 adult volunteers each year. The majority are seniors. Volunteering improves health and 78% of our adult volunteers improve their eating habits after getting involved.

There are two main reasons why we are seeing the skew toward for-profit providers. The first is that there is an unlevel playing field. For-profit organizations can afford to charge low rates to gain market share--many of the big companies in the medically tailored meal space are venture-funded.

In addition, they may offer a one stop solution for plans operating across multiple counties, providing an incentive for plans to bypass the more time consuming effort of contracting with multiple community providers. Partnership has done a really excellent job of contracting locally, but there are other plans that have not.

The second issue is that the risk return calculation currently does not make sense for most community providers. Standing up claims, billing capacity is expensive, time consuming and often requires expertise beyond their current staff. I have two and a half staff memberes who are just managing contracting for us that we hired away from FQHCs.

Reimbursement rates for many community supports don't cover the full cost of providing the service, including the administrative burden of operating in Medi-Cal. The rates recently introduced by New York and Massachusetts for medically tailored meals are 50% higher than the rates in California.

Rates directly tied to quality through the ability to hire and retain staff, which others have mentioned. Finally, there's no guarantee of how many referrals you might receive, and plans can choose to stop offering a community support at the end of each year. Given these conditions, it's impressive that we have as many community providers contracted as we do.

We believe that CalAIM offers a transformative vision of health and health equity. But, success depends on the engagement of far more community providers than we are seeing to date.

For that to happen, we must change the rules governing how Medi-Cal managed care plans contract and with who, and create stronger structures to make contracting viable for community providers. Thank you.

Thank you so much. Now I'm going to turn over to the Vice President of Regulatory Affairs from LeadingAge.

Yes, Good afternoon. Thank you, Madam Chair and Members. It's a pleasure to be here. LeadingAge California is an association that represents housing, care and services for older adults. And we have a lot of nonprofit members, over 800 in the State of California and most counties. And our members also provide CalAIM community supports.

On a personal note, I'm a gerontologist. I've always had a passion on helping older adults thrive, and I worked in direct services in older adult affordable housing for almost 20 years. So, I know firsthand the aging in place needs of older low income Californians, and that's actually how I ended up in public policy.

So, glad to be here today. And to share some suggestions on ways that we've heard from older adults and our members on how to increase uptake of CalAIM community supports.

So first, just wanted to say that we're so glad that these community supports align with the Master Plan for Aging, which is the first in the nation, is really revolutionary in creating age-friendly communities for every county in California.

The community supports provide essential services that can help older adults remain in their homes and communities and can help them transition from institutional settings like schools, nursing facilities back into the community.

Based on feedback from older adults that I speak with frequently and members of our association, we really want to explore some opportunities to radically increase uptake on CalAIM utilization for older adults. And the first one would be our suggestion to create older adults as a population of focus.

So we've talked about population of focus several times today, and we believe that having a population of focus for older adults similar to the existing designation for children and youth, would create a more inclusive framework enabling more self-referrals which are so important according to what you just shared for the meals, and also community referrals tailored to the unique needs of older adults.

We'd also like to suggest that DHCs form a community of practice with managed-care organizations, associations and providers and older adults to ensure that everyone can start working and talking together to create a solid game plan that involves rapid provider outreach and credentialing so that every qualified older adult in every county has the opportunity to receive assisted living services and other community supports.

One of the things that we think that might seem too simple, but might be another important tool to increase participation is to rename one of the most underutilized current community supports now called Nursing Facility Transition/Diversion to Assisted Living Services.

A lot of older adults don't think of themselves as having the nursing home level of care, even though they do. And we really know that they're interested in something called assisted living. We think the current terminology creates confusion and is not relatable, and we want to be more upfront and approachable with the term assisted living services.

So I'll use that term for the remaining moments of my time here. When older adults need more help, they often prefer to live in assisted living communities. Assisted living is a homelike setting that provides support with daily care and household tasks and includes socialization and recreation to combat loneliness and isolation, which are epidemics.

Also, the Assisted Living Waiver program, which I already spoke of, started in 2009 and has always been really popular. Even with the increased number of slots, I'll just underline what we already heard today: we have a wait list of more than 7,700 people in the 15 counties where it's available.

And we do believe that CalAIM Assisted Living has the potential to wipe out this wait list as we've talked a little bit more about earlier, and also bring assisted living to the other 43 counties that have largely gone underserved with assisted living services.

In regard to the assisted living community support, we have about 2% of our facilities statewide participating, so we think that there's an urgent need to enroll and expand access by enrolling many more providers, RCFEs, Residential Care (Facilities) for the Elderly into this community support.

We suggest that CalAIM include pairing affordable housing buildings with home care services deliver assisted living as well. This is allowed in the Assisted Living Waiver, and doing so through CalAIM would also allow residents to remain in their affordable homes where their rent is sustainable and bring the assisted living care right to them.

Another needed mechanism is for DHCS to issue an All-Plan Letter, advising all managed care plans to credential all of the current Assisted Living Waiver care coordination agencies as CalAIM ECM providers.

These CCAs with the Assisted Living Waiver, if many of them were to become Enhanced Care Management providers, they would already have access to the waitlist we were talking earlier with the portal.

They already know who's on the waitlist, and if they could be able to place people in whatever program is available, we think that that would help, before the portal is available to have a lot of people move off that waitlist and into the Assisted Living program right now.

DHCS also has the opportunity to increase access to older adults by making the MCO system much less complex. Right now there is unnecessary complexity from variations in receiving referrals, communicating with staff, billing and rate setting. Our members want to suggest that DHCS survey providers to glean which MCOs have best practices.

We heard that partnership is doing some really great things and so is CalOptima and others. And then make these best practices uniform throughout the state, like your bill.

To illustrate the real world impact of these services, I'd like to close by sharing the story of Maria, a 70 year old woman who has experienced homelessness for over a decade before receiving assistance through the Assisted Living Waiver program.

Thanks to the ALW, she now has a home and assisted living community, ongoing case management and assistance with daily activities.

I'd like us to imagine how expanding access to the Medi-cal Assisted Living program through CalAIM can transform more lives of more older adults and also their families and their communities by providing them with stable housing and necessary care. I would like to just thank everyone for the opportunity to talk about these things today.

And we're ready to continue to talk about proposed solutions for CalAIM utilization among older adults.

Thank you. Now turning over to the CEO for WellSpace Health.

There we go. Thank you. My name is Dr. Jonathan Porteous. I'm the CEO of WellSpace Health here in Sacramento. We serve Sacramento/Placer counties. I'm also a licensed clinical psychologist. Firstly, I just have to say I can't be more grateful that I'm actually sitting here with you at a time like this in D.C.

Because to hear what the director says about, you know, we want this program to continue regardless of that climate is incredibly reassuring. I represent 140,000 patients here in this region. I run an FQHC across 30 sites. I run a certified community behavioral health clinic. I run the 988 system for 32 counties across Northern California.

We run the biggest residential rehab detox facilities around the region. So, you know what's going on is extremely threatening. I also am here to say that I'm very worried about how threatened CalAIM could be. My organization's been providing services that became CalAIM services since around 2005.

Until 2022, we had probably provided 250,000 touches to things that look like ECM and CS. And then we were able to take it forward with CalAIM. And it's been stunning. We heard from the Western Center that we need outcomes.

And my dire concern is that when CMS comes sniffing around, we're not going to be able to say what we are doing in lieu of, you know, this is in lieu of, and what are our outcomes? When I hit the brakes, my speed goes down. When I touch my phone, it tells me I touched it.

So all these touches we've done through CalAIM, what are their impact? And I'm terribly concerned that we're not able to show the reduction in ER utilization, the increase in provider engagement across all populations. So that's a very kind of high level, but dire concern that I have. And I then also see that kind of the breakdown.

Senator Richardson said, you know, then there's mental health. So she talked about the CalAIM services, then there's mental health. Senator Arreguin said, and how do we pay for that? I run a crisis receiving site downtown here. You're very welcome to come. Dr. Weber's been and a number of your colleagues. We see people who need sobering.

We see people who are psychotic. Usually they come in both so psychotic and intoxicated, right? 20% of those persons are covered by CalAIM through the sobering benefit. So what do we do for the rest? We heard about that connectivity with the criminal justice population and we have an FSP for the JI population here.

And how do we create that connectivity between CalAIM and other services? How do we create services that can and speak across counties? And I have to say that my biggest pitch here today has to be, could we please run a pilot for the certified Community Behavioral Health Clinic in California?

This is a program Tom Insel, who ran the National Institute for Mental Health--15 years. Yesterday he was at a meeting and he said, California is driving blind. Everyone else is doing the CCBHC. And this is a program with massive federal support in terms of the FMAP.

It's a program that really liberal states like Texas and Kentucky and Oklahoma have taken on as a best practice and so has New York. And it's kind of weird when New York and Texas agree on something. All I can say is when we have the opportunity, 85% match on mobile crisis in the Medicaid population.

When we have that opportunity sitting out there, it's not a waiver, it's a program that the fed support. All I can say is can we please bring that in to marry the CalAIM? Because it's just going to just exponentially make it better.

I would want this to be smooth first before adding additional programs to it. We have noted that. Thank you so much, Dr. And our last provider here is going to be from Full Circle Health, our CEO here.

Yes, good afternoon Chair and Senators, thank you for the opportunity to be here today to talk about the important opportunity we have to improve the health and well-being of California's most vulnerable children, youth, and adults. My name is Camille Schraeder, and I've spent my entire career focused on that mission.

I've been driven by my experience being raised in foster care in Idaho and California, in rural California over 40 years ago.

I sit here before you today as the CEO of Full Circle Health Network and my colleague earlier, Vika spoke a little bit about hubs and the idea and the proposal for regional hubs within the justice involved space.

And I'm here as a hub and presenting that as a potential opportunity to lift up all community based organizations who are unique in their communities to be able to provide the CalAIM benefit regardless of small, medium or large and also to assure that there's a comprehensive model of care across all of that by population of focus.

In less than two years, Full Circle Health has become California's largest community network hub serving children, youth and as a result of need now vulnerable adults. We in partnership with more than 100 providers spanning 35 counties are committed to delivering coordinated care through integrated ECM as a key to bridging the medical and social care systems.

Full Circle was created by and for community based organizations under the California Alliance of Child and Families. The CBOs have decades of experience working with vulnerable populations from child welfare, public safety, homeless crisis and behavioral health systems.

The alliance board saw the need for technical infrastructure, expertise and support to enable CBOs across California to contract with managed care plans in order to integrate and provide these benefits.

We also hope that this hub model is an opportunity for other social service and statewide initiatives moving forward to bring things both quality, comprehensive work and services to scale regardless of the county you live in. In 2024, the RAND Corporation confirmed what we already knew for decades of experience doing complex care delivery.

The best way to engage system involved children and families in enhanced care management is when it's offered by agencies they already know and they already trust: Agencies that are embedded within their communities. Agencies with staff who understand them and deploy trauma informed care models. Agencies that know how to make connections between systems and coordinate services across providers.

Those agencies, our community based organizations, are essential to addressing the social determinants of health and reducing health disparities. They are savvy when it comes to understanding what their clients need and how to get it. But many of them do not speak managed care. That is why Full Circle exists. We translate the expectations, the lingo and the workflows.

We have a fully operational platform that is built to support the providers from outreach all the way through into claims and claims management. We support the reporting and administrative contractual requirements. We train providers and provide mentoring and coaching for all aspects of the work. We partner with our providers to share best practice and refine care delivery strategies.

And we reinforce and support the health plan standards and drive consistent quality. We believe that hubs like Full Circle benefit CBOs and the managed-care plans leading to more members receiving these services.

CBOs get to focus on the core competency of person centered services delivery and managed-care plans have an efficient access to a cohesive local grassroots CBO network implementing a standardized model. Full Circle is a neutral organization that does not deliver the direct services. We do not compete with our network providers.

We are built to strengthen the CBO community. We succeed when they succeed. Our sustainability is directly connected to the providers developing this service. We would not exist without the startup funding from DHCS and the health plans through PATH CITED and IPP grants. We appreciate the Department's vision and the support for hubs.

High performing hubs are a key strategy to increase ECM, CS and CHW service delivery. Because hubs increase the number of grassroots local CBOs participating in the CalAIM programs, hubs allow even small CBOs unique, niche CBOs who serve specialized populations to actually be able to integrate this the CalAIM benefits into their other service delivery system providing an overarching wraparound trauma informed practice. We are seeing progress.

ECM enrollments are increasing, but what more can we do? Just a few suggestions: DHCS could create some clear regulatory guidance to strengthen, simplify and promote managed-care plans comfort in contracting with hubs.

We could continue to encourage DHCs and managed care plans to listen to the providers about requests for standardization across managed care and to continue aligning forms processes with less reliance on individual managed care plan portals.

That's particularly a struggle for counties where there's multiple plans where you're going inside, having to teach staff and then and I know DHCS has given lots of recommendations, guidance around this, but the continuing attention because it has not yet influenced the work.

Build out and maximize education and marketing of CalAIM benefit where the beneficiaries go, such as schools, community centers, doctors, public system offices, homeless shelters.

In order to normalize this offering to the people who qualify and need it. Our kids, families and vulnerable adults don't trust, and they need to actually understand that this is a real service when you're coming to approach them to say: Hey, do you know that you may qualify for this benefit?

So, it's very important that they be able to trust and normalize the experience. And I feel like we all of us have not done enough to really get it out into the street. And that's one of the problems with utilization. Last recommendation, build out some advanced work around internal referrals.

So reverse referrals, we call them community pathway referrals. Referrals from the CBOs, from the community to the plans. That system is individual to each managed-care plan, but probably does need a little bit of attention to automation, technology and speed of acceptance.

So we appreciate DHCS's new requirements to streamline and improve the authorization process that went into effect in January 2025. Presumptive authorization for some of the highest needs populations of workers like mental health, child welfare will significantly--

Appreciate it, thank you so much. We're going to cut off right there. Thank you. Thank you. Thank you, thank you. Thank you. We can continue in conversation. I promise, I promise, I promise. Okay, we're going to start off with Senator Rubio. Thank you.

That was a lot of information, but there was something that I heard that was very concerning to me, and forgive me if I'm not accurately stating some of the data that you just pointed out, but you know, from what I heard earlier, and all of you said something, so I don't know who exactly said it, but you stated that 70% of the funding that is made available to provide quality care is diverted to for-profit agencies.

And then you set the 14% of it goes out-of-state. So what is left to provide quality care for the people we intend to care for?

So, I think this is really again the mix of the barriers that small CBOs have to actually enter the Medi-Cal ecosystem, right? We spent nine months, we had already--so we worked with DHCS for a Medically Tailored Meal Pilot back in 2017. And we're part of a national coalition that does healthcare contracting.

So we entered this with a lot of stuff already behind us, we're a $5 million organization. We had to bring on two and a half staff and it took us nine months to figure out the tar process and claims billing with partnership. And again, we are still not billing enough referrals to make this cost effective.

And all of those steps to actually enter the Medi-Cal ecosystem--you know, I think that we did this because we believe food is part of what is causing chronic disease and needs to be integrated as a covered benefit. It was a mission decision, not a financial decision to step into CalAIM.

And most smart CEOs of nonprofits are looking at this and saying, why would I do this because I'm going to spend all this money and there's no guarantee that I'm going to get referrals or that the rates are going to be cost effective or that this is going to stick around, right?

So we're asking people to do something that's very expensive and time consuming without any kind of guarantee at the end, right?

And at the same time, at least in Medically Tailored Meals and I think in other areas of healthcare, as healthcare dollars become available to address social determinants of health, there is a tremendous amount of venture funding going into the standing up of national nonprofit tech-based solutions for a lot of these things.

They can afford to charge low rates. They are mostly not based in the communities that they're serving. And for a plan that is--for some plans who are in multiple counties, this is an easy solution for them. I can sign one contract. I've checked the box that this service is available.

So there is both a, like, as I said, an unfair playing field from the for-profits and a lack of like a risk return calculation that makes sense on CBOs and a lot of barriers to entry. And that's left the plans kind of moving towards these for-profit providers as solutions.

But I have a comment to follow up on that, and I understand what you're saying, but you know yourself, you're listing almost a menu of challenges that you have moving forward. And you talked about, you know, just the rate of return, billing capacity and on and on.

So when we talk about the number of funding that the amount that's going out, I mean, my brain automatically goes to putting a cap. But then what does that look like?

Let's just say, so in a magical world that there is a cap, wouldn't that also now cause these challenges on your side in terms of trying to catch up with capacity and staffing, and so tell me what that looks like?

So, we think that there's--so, this comes out of literally hundreds of conversations that I've had with CBO leaders and coalitions across the CSECM space over the last two years. So we have, I think, five things. One, right now, DHCS encourages the plans to contract with community providers. We think that needs to be stronger.

That plan should be required to contract where community providers exist in the community. The second one is rates need to cover all of the costs of providing the service, right? There's administrative costs of operating in Medi-Cal that need to be built into the rates.

The simplification of administrative complexity across plans is a really important one. Uniformity of people who are either operating in multiple counties with multiple plans or multiple plans in one county creates an incredible burden for the CBOs. The fourth one is allowing subcontracting.

So hub models where small CBOs cannot have to do a lot of this stuff and let the hub come in and take that over. That is a part of the solution.

And the fifth one is, you know, CalAIM and especially community supports, but also ECM to some extent, depend essentially on bringing in a new group of providers into the Medi-Cal ecosystem, right? CBOs that have been working in the community, but not working in Medi-Cal and within the ecosystem, CBOs have the least amount of power, right?

You've got plans, you've got the state, you've got providers, and now you've got this new group of CBOs who are new to Medi-Cal, don't really understand Medi-Cal, and don't have a lot of power in the ecosystem.

So also elevating the voice of CBOs in a structured way so that we are at the table when guidance is being recommended, when rates are being set, instead of getting that after the fact. So, those are the recommendations that we have.

You know, thank you for that, and it sounds, you know, a perfect world, right? But, you know, I do worry because we start going into--I mean, you even talked about subcontracting, and then you get into other problems like who are these subcontractors? You understand there's other issues that come along with it.

I'm just trying to understand it, and I think we've already taken a lot of time, and I can see our leader here trying to move forward. But I do appreciate what you're saying. I'm just saying we have to be cautious when we shift from one thing to another, then we may create unintended consequences on the other end.

My first thought is will we have capacity? Yourself said that we don't have people. There are enough providers and people that can serve.

There are so many providers on the ground that are already doing this work, as you mentioned, already doing this work, but have not stepped into Medi-Cal because of these complexities, right? So we need to simplify and streamline and prioritize community--based providers.

There are plenty of providers on the ground to do a lot of these services. I mean, think about the, you know, Older Americans Act programs in almost every county that are providing home-delivered meals. Most of them have not entered the Medi-Cal ecosystem, but certainly could be providers.

And Senator Rubio, your point is very well taken in that you need to have a compliant and clear picture of what a hub model is. But in the model we're describing, it's a centralized system whereby those CBOs can continue to be in their communities doing what they're doing.

We're teaching them the competency, capacity, oversight and support to be able to enter into managed care plan contracting either through MSO or master contracting models so that we build out the capacity in the community where those children, families, adults live and breathe the people they know, the agencies they know without expecting.

There's so much change happening in CalAIM and I mean, God bless everyone for all, everything--it just changes all the time. And having a technology system that is fully developing every day, new changes by new health plan is very arduous for community-based organizations who may or may not even have the ability to make those kinds of changes. So that's a way to do it where you're managing it in a compliant and safe way.

Okay, thank you. I'm done.

You know, Senator, if you're upset about the contract now and all that, you should be a co-author on my bill. I'm looking to address that.

Director, when we're looking at places like Full Circle Health or other entities like Partners in Care, do you believe that those are the solutions that would help these local CBOs be the providers?

We are definitely supportive of community care hubs. We've provided path dollars to support their development and infrastructure to do that. I mean, our contract with our managed care plans, we say they must prioritize locally available providers. Must. It's not a recommendation, it is a must.

We recognize the value of local community partners who know their communities, who are trusted in their communities and we want to uplift that. Under CalAIM, really, the definition of who provides health is kind of undoing decades of kind of the way things were. It is no longer clinicians, it's peers, doulas, community health workers, CBOs.

And we've provided a lot of dollars to try to build that up. Recognize there's still plenty of work to do. But really, I mean, I think we're in alignment with everything that's been said here. It's just we need to continue to build upon it.

It's true. And the doctor brought up a question I was going to bring up regarding, like, how are we measuring our success? Like, how are we auditing the money that is going out? Is it being used in the way we want it to?

Happy to take that. So our finance team is not here, but certainly there's financial oversight. And so for ECM there is a risk corridor in place. So for the first few years, because again, we're scaling the program, we're still rolling out until last year, new populations of focus.

The plans are prepaid, they enroll individuals, but you know, if they sort of spend more money because there's more uptake than expected, they're protected. If they don't spend all the money because uptake is lower or slower in some areas, we claw that money back. So there's financial oversight built in through CalAIM.

And then from an outcomes and quality perspective, which I think your comments were on, obviously when you stand up a program, the first few years were just nuts and bolts, like, do we have a provider who can accept this individual? Are they providing services? And that is that utilization data that has been flowing out.

We are fully committed to the next step, which we are sort of thankfully now at of what are we getting for that money? What does high-quality ECM look like? And we know there is variability.

You know, if you're a large organization that's doing mostly Telephonic ECM, you know, I would say that's not even really ECM, but that is different than sort of high intensity in the community. home visits for multiple hours per week.

And so as a part of our CalAIM Population Health Management program, we are launching, or we've launched our Medi-Cal Connect platform. It is currently only for DHCS users, but we'll be rolling out to plans and providers over the next year or two. But through that we are now able to crosswalk. Okay, who got ECM?

Who got community support? What do their health outcomes look like? Is ED utilization or hospitalization going up or down after a few years? You know, what is their blood pressure control? Or diabetes control look like.

So what are we getting as well as doing advanced analytics to answer some of those questions about the touches, like is there a difference in outcomes based off of type of provider or face-to-face versus virtual visits or geography to really understand, you know, where do we need to issue additional guidance once we have those lessons learned

And you brought up the telephonic portion of it, how are we ensuring that most of it is in-person and they're not counting telephonic services as an ECM?

Yeah. So there's different billing codes that, that's the data that's coming in. So if a telephonic care management touch is rendered, that code is different than an in-person face to face so that we can look at it.

We do want to be member-centered and for some of our members, because of what's happening in their lives, they, they do want a telephonic, you know, visit as opposed to someone coming into their home or to their community. So at the end of the day, member choice will outweigh anything else. But, otherwise it is required to be in-person and face-to-face. And we can track that through the billing codes.

We track it, we have all this information. Then what, how do we then adjust?

So, starting again. The last few years have been very hectic just rolling this out. Thankfully for ECM, at least our last populations of focus rolled out last year. So we are now moving into the monitoring and enforcement part of both ECM and community support.

So, you know, both mine and Susan's teams work together where we have monitoring sessions that our staff are looking at those data and outputs on a regular basis and then setting up meetings with all of the managed care plans to review, you know, where are things going well and what bright spots can we learn from that and scale across the state and then where are things not looking so good?

And then as necessary, placing plans on corrective actions and further enforcement actions.

If I may, the plans--I'm on the board of Partnership Health. I talk with the commercial plant. They're all saying that they're providing all the data. And I want to say that I think they're right. I know you may have a difference of opinion.

So I think their major request has been can the policy and the data people talk to each other? Because they want you to protect them from CMS.

Say that again.

I know they're very excited by what you're saying. They want the policy and the data people to talk to each other and then protect them from CMS. They're all totally invested in CalAIM. We're all invested in CalAIM and it's incredible. We've got great leadership.

It's about having the resources to bring the data, the policy together and talk about it.

Yeah. And I will say my team is responsible for the policy along with Susan's team, but also the program evaluations and many of the data analytics. And so for, you know, we have all the data. So, if and when we need to demonstrate the validity and value of CalAIM, I'm confident that we can do that.

Certainly for ECM, and then for community supports, we are actually required by CMS to do monitoring and a formal program evaluation to demonstrate the ROI and value of community support.

So that is in our special terms and conditions and that data and regular reports as well as the final program evaluation are being collected and will be sent to CMS.

And that's the bit where we're anxious because it's been a while and we're just, we're trying to feel the feedback and again, no disrespect, just that's what it is.

No, all good comments and I asked director about the need for these kind of hubs and so forth. Very supportive you mentioned. Is there anything else we can do to further empower more of these kind of hubs?

Sure. Yes. So we have a few ideas that we've been discussing actually with our plan partners as well as hearing directly from our community-based organizations. I think some of the things that we could provide in terms of additional guidance is really to clear up some confusion of plans' responsibility.

Ultimately we have a contract with our managed care plans and the plans are responsible for ensuring compliance. We want to make sure that whoever they contract with actually can deliver the services that they are required to deliver.

So, there has been some hesitation where some plans are worried about using hubs and whether they're diluting their own ability to provide that oversight. So we are working to make sure we can provide some additional guidance to clarify when perhaps certain things might be triggered, and again when they is essentially how they can ensure compliance.

Potentially maybe allowing then, MCPs to contract with these local CBOs, removing that fear, right?

Yes, and they have that flexibility now. I think some of it is just clarifying and continuing these conversations.

Linda brought up a comment regarding some feedback that came last year from advocates, and so forth, and the guidance now going to be or defining the definitions, right? It's going to be starting in July, almost a full year's worth taking that feedback and starting that two parts to this.

Why so long? And two, is as we're hearing more feedback, are we then going to feel pessimistic and say, well, what's the point? It's going to take a whole other year to implement this feedback.

So for the feedback that we do receive that we can act quickly on, we really do intend to act quickly. But some of these kinds of conversations, it's a matter of we put out draft policy, try to get feedback to make sure we're actually addressing the concerns, take in public comment.

So there's generally processes for when we update our policies. Recognize everybody wants us to move more quickly, but we do want to make sure we don't just come out with something that is not really addressing the problems, doesn't have stakeholder and kind of feedback from our partners in terms of does this address the challenges?

Is this the way to do it? And then we do have to give our plan some lead time to actually make the changes, whether it's IT systems, process flow changes. They, you know, our plans can't turn overnight, even though I know they would want to. It's just there are things that need to happen.

And so, you know, I don't know that everything will take a year. But I think that some of these significant changes where we standardized the referral and kind of the way these things that is, that was a monumental change for the Department and for kind of our ECM way we do those referrals. And so it did take some time.

So, but where's there still--the door is still open to continuously-- You wanted to add something?

I just wanted to add that one specific item related to the housing deposits. So there was some confusion, right, about some plan saying, well, you must have these housing deposits before you get housing deposits.

And we actually did amend the plan contract to clarify that can't be a prerequisite because essentially we do know that, yes, it would be ideal for a member to have housing, navigation supports, sustaining supports, because if you get a deposit, that means you have housing, and we want the member to be successful.

We want them to be able to sustain that housing however members can--there's member choice that always trumps everything, and then there could be other services that are being provided where another nonprofit organization is actually providing the sustaining services. But it's not technically a community support, but it's being provided in the community.

So we didn't want to crowd out all that good work that's already being done and still make sure that members have direct access to the housing deposits.

And to my providers here, how difficult is it, given the housing shortage to actually connect and utilize this service?

That is another reason why the community-based organizations on the ground are the best ones. They're connected to the CoCs. Many of our providers are homeless providers and so they know the landlords, they have relationships. The landlord's going to trust that they say that they can do it.

The primary challenge, and I do think that all these things are improving is that turnaround time to payment.

So because most community-based nonprofits that are doing homeless services in communities outside of LA, San Francisco or San Diego can't actually carry the kind of cash flow that it takes between if it were 30 days, 45 days, but those things are getting better. Just some focus on that.

But that's one of the reasons why your community-based organizations really are the primary for that. And, and I did want to just finalize with the presumptive authorization issue.

Around the population focus that we serve has been a game changer in actually engaging the member who needs it at the point in which they get the assessment and are found to be eligible for that service.

I have story after story of grandmothers and their kids and huge amount of difficulty where when they could immediately upon that screening begin serving and then get the authorization later and know that they would be paid. I just really want to give a call out for that. Especially in the child welfare field and the behavioral health. It's been a game changer for them.

And having been the chair of our CoC for a number of years here in Sacramento, all I hear is $600,000 a door. You know, I just constantly get that feedback. I believe the housing stock is coming up. What I have seen is that we should probably focus mostly on what seems to be making housing manifest.

I mean the governor's safestate community here in Sacramento is an example of us getting land, and there it is. And we have to kind of go upstream with some of the NIMBY issues I think and get community collaboratives.

But as the more substantial housing stock comes online, the real walls and real buildings, you know, maybe some of the, some of the kind of safe stay community, tiny home. I'm not a fan of tents that those things that work faster. We need more of that.

And one final question I'd like to ask also both you and then when the plans come up is, we've heard a little bit of what, you know, the hubs provide the ability to remove a lot of those barriers.

What additional barriers need to be removed, move to help managed care plans partner with local CBOs or what do CBO's need? What additional support do they need to be able to partner?

I mean, I think rates have got to be sustainable, right? It's like we can't--we're subsidizing every single Medi-Cal member we serve with philanthropic dollars. And we had a fair amount of funding. We got two rounds of path funding, two rounds of IPP. That's done now for us.

And now the rates have to actually pay for the cost of the service. Right. Otherwise we're asking our donors to pay for Medi-Cal members and it's, you know, we just can't sustain that. So I think rates is really, really important.

And rates being set based on community-based providers and what it takes for us to do the service in the way that we do it on the ground, which is, you know, a richer intervention than what a lot of the for-profits are doing. Prospective payments could be helpful, I think as well.

And you know, I will say I appreciate that you said that plans must prioritize local providers, but all plans are not doing that. And plans need to be held accountable. There are plans that are, that are basically not contracting with almost any local providers for Medically Tailored Meals.

And you know, 25% of the members that I serve in Sonoma and Marin no longer have a direct local provider because of Kaiser's direct contract. So they are not doing this and, you know, "must prioritize" isn't working in some areas, but rates is the big one.

Yes, and the other thing that I mentioned before is so important is uniformity. Our aging services providers often work with multiple plans in one county or some of them work across the state. And having to have different codes, different relationships, different procedures and forms for each plan is really difficult for their state.

They even have to split staff into plan relationships and they have staff that specialize with different plans instead of specializing in the older adults that they serve. So uniformity is key.

Thank you so much. I appreciate it.

Can I leave one pager? Because for me, 23 years as a clinician building an integrated system of care for 140,000 people.

Absolutely.

Can we fill the space with the CCBHCs? It's a workforce pathway also for everyone in this space with CalAIM, it's the next step for them.

I got 10 years here. We'll work on that.

Thank you, ma'am.

Can't give the director a heart attack, you know. Thank you so much. Have our last two panelists come up representing their plans. I really appreciate the plans coming in today. I think it's imperative that we hear the perspective through the lens of every single individual involved in this CalAIM process.

So we have CalOptima Health and Kaiser joining us today.

We'll start with CalOptima Health.

Good afternoon. Thank you so much, Chair and honorable Committee Members. My name is Yunkyung Kim. I'm the chief operating officer for CalOptima Health, and it's my pleasure to share with you our experience in implementing CalAIM today. So CalOptima Health, we are the local Medi-Cal plan for Orange County.

We have proudly served our community for 30 years. We are a county organized health system. What that means is that with the exception of my colleague Kaiser Permanente statewide arrangement, we are the single Medi-Cal plan for Orange County. We serve nearly 920,000 residents of Orange County.

That's nearly one in three Orange County residents and we provide them with Medi-Cal. We also have a Medicare Advantage Dual Eligible Special Needs Plan and a Program of All-Inclusive Care for the Elderly, PACE. I'm also pleased to share that we recently received approval by our local community to pursue entry into Covered California.

So CalOptima Health launched CalAIM in January 2022. We offer all 14 community support services. We were one of the first plans in the state to do so. And we made that decision from the get go that we would offer all 14. In the three years since we began the CalAIM initiative, we have provided 93,000 members with CalAIM services through through a local network of 100 providers and nearly all of them are local to our county. As a local plan, it is important for us to support and promote our local partners. As was stated and discussed earlier.

I'll share some of the approaches that have guided our implementation of CalAIM, and I'll keep this brief. One thing that we chose to do was we chose to invest in our community. So one thing that we did was we initiated what we call the Enhanced Care Management ECM Academy.

And that is a six month program that all of our ECM providers are required to complete. We use the six months to learn about how to work with a health plan because we know that we're not always easy to work with. We go over what's in the contract, what are we actually expecting from our ECM providers. You know, what does in person look like? What does telephonic look like? We go through credentialing, we learn about the referral system, how to make a referral, how to get a referral, we learn about claim submissions.

We also ask our ECM providers to do financial planning to make sure that this is a sustainable program for them to embark on. At the end of those six months, there is A better understanding of what to expect in this relationship. And we have built the relationship that helps us problem solve when things don't go to plan.

Once the academy is over, we don't just release our ECM providers into the wild. We also have an ongoing CalAIM Academy, which is a bi-weekly opportunity for our providers, all of our ECM providers, to learn about things like, you know, claims refreshers, referral refreshers, but also things like what are some best practices in outreaching to members.

In addition to the academy approach, which we have also used for other services, we have also provided over 170 capacity building grants to our local providers totaling over $44 million. And that was to build up the local ability to provide CalAIM services. This included seed funding to get started or increase staffing, pilots to test system changes, and incentives to implement innovations.

Lastly, we initiated a nonprofit academy where our smallest organizations, community organizations, could learn about how to play this game, how to play in this field, how to get contracts from funding organizations. It helped them with things like learning how to do grant writing, program design, program evaluation. Again, increasing their opportunity to compete for programs, not only with CalOptima Health, but also with other potential partners out there.

So I'll stop here and I'm happy to answer any questions, but I will just say as a local community, one of the things that we've learned, and I appreciate the comments by the department leadership, that it has been a fast and wild three years. But one thing that we embarked on this early on was we were honest with our community that this would be messy, that we would make mistakes, and that we would learn along the way and that that feedback was bidirectional.

We wanted the feedback and that we would provide the feedback. And we are at the place now where we believe that we are getting very honest and transparent feedback from our community stakeholders, and we are able to now show them also here's how we see you doing and how can we move, as a county, the program forward together. So thank you very much and I'm happy to answer any questions.

That's really great. Thank you so much. Like to turn over to our next plan from Kaiser.

Thank you. All right, Chairman Menjivar and Members of the Committee, thank you for the opportunity to be here today for this important topic of Medi-Cal and CalAIM. My name is Arif Shaikh, Senior Director of Medi-Cal Policy and Engagement at Kaiser Permanente. Kaiser Permanente is committed to Medi-Cal transformation.

And DHCS's goals to strengthen local partnerships and to support innovative care models that improve health outcomes. Our Medi-Cal Managed Care Plan contract with DHCS reflects our commitment to serving the Medi-Cal population with a focus on quality, equity, and community based care.

Through our collaborations with county agencies, community based organizations, and providers, Kaiser Permanente and Medi-Cal members receive high quality coordinated services. We remain committed to working alongside DHCS and our local stakeholders to drive sustainable improvements that enhance health equity and improve health outcomes for California's most vulnerable populations.

Kaiser Permanente delivers most enhanced care management and community support services through what we call network lead entities, which coordinate the provision of care while expanding local relationships. This strategy, approved by DHCS, enables Kaiser Permanente to maintain a broad and agile network of community based providers across our 32 counties.

Kaiser Permanente chose this network lead entity model to engage more local organizations in the delivery of services while retaining health plan administrative oversight functions within Kaiser Permanente. At the same time, the network lead entities support community based organizations providers with capacity building, training, and analytics.

Designed to scale across 32 counties, this model enables timely access to enhanced care management in all 14 community support services. By engaging county partners and over 250 community based providers, of which 170 are not for profit, our model strengthens local partnerships, provider networks, and enhances care coordination.

The Kaiser Permanente Integrated Delivery System is at the foundation of our Network Lead Entity model providing access to clinical care and services. Our goal with launching the Network Lead Entity model in January 2024 at the beginning of our statewide contract was to ensure that all members had access to enhanced care management and community supports in all 32 counties, and also to provide support to those community based organizations who are new to Medi-Cal on day one of the new contract.

Since launching this model, we have continued to listen, learn, and adapt. Throughout 2024, Kaiser Permanente hosted several stakeholder listening sessions with prospective and current community based organizations to gather feedback and shape an action plan to improve processes, enhance patient and provider experiences, and drive measurable outcomes and awareness, referrals, network development, and also stakeholder relationships.

We continue to actively gather feedback on the model as we remain committed to learning and continuous improvement. Kaiser Permanente's Medi-Cal Local Engagement Team, deeply rooted in the communities we serve, fosters meaningful engagement with community providers, county agencies, Medi-Cal managed care plans, and other key stakeholders within the larger Medi-Cal ecosystem.

With over 1500 external engagements and 500 Medi-Cal trainings in 2024, this team is focused on driving local collaboration. Also through the Incentive Payment Program and the Housing and Homelessness Incentive Program Kaiser Permanente, is making investments in community based enhanced care management and community supports providers, as well as county agencies, to build their capacity, increase member engagement, and strengthen the broader public health ecosystem.

As stated earlier, we're very proud to partner with over 250 community based providers, again of which 170 are not for profit, to provide these critical services to keep our members healthy and thriving. We look forward to continuing to work with community stakeholders to strengthen and expand local relationships and ensure Medi-Cal members have access to high quality community based care. Again, thank you for the opportunity to be part of this discussion today and look forward to the discussion.

Thank you so much. We'll start with some questions to KP. You mentioned the Network Lead Entities. Did you start from the get go with that approach?

With the statewide contract, yes.