A Monthly Digest of Information and Resources on California’s Efforts to Transform the Medi-Cal Program
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Melora Simon, MPH, Associate Director,
People-Centered Care
Since CalAIM launched, we have been closely following the efforts of health and social service providers working diligently to provide person-centered care for the people they serve. This month we’re devoting the digest to the release of a major research project from CHCF, In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care. The report captures the perspectives of Californians who have firsthand experience with these programs.
Our goal was to bring their perspective directly to you. It also offers a reminder that there is no substitute for including people with lived experience not only in the workforce — a key finding of the study — but also in program design and implementation.
Highlights
Key findings: Six insights from Californians with multiple health and social needs
A new CHCF report shares the perspectives of Californians with firsthand experience interacting with the health and social services system for treatment and support.
Reflections from implementers: Providers and managed care plan leaders respond to the report
An advisory group of providers and managed care plan leaders offered insights for putting the findings into practice.
Key findings: Six insights from Californians with multiple health and social needs
In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care is a major research project conducted by EVITARUS in partnership with CHCF. It is based on interviews with 99 Californians and eight caregiver focus groups in Alameda, Fresno, Humboldt, and Los Angeles Counties. Participants met at least one of four criteria: They were experiencing homelessness or housing insecurity, living with serious mental illness, facing or recovering from substance use disorder, or living with functional impairments such as hearing loss or cognitive decline.
The findings reveal some universal needs — most notably, participants’ desire for trust, empathy, and respect — while also highlighting the challenges people with multiple needs face when trying to access services and navigate complex health systems.
1. Most participants experience several complex needs simultaneously. Eight in 10 participants (83%) reported having a chronic health condition in addition to acute health and social needs. Virtually all participants (97%) had at least two complexities, while two in three (65%) had four or more. This has widespread implications for the number of systems people with complex needs must navigate and the types of support they need.
2. Trust with providers and staff is crucial. Over half of participants stressed the importance of being respected and empowered as patients, which meant being asked about their goals and needs. They reported having positive experiences with providers who reinforced their humanity, respected their sense of agency, and saw them as a person. Many participants said they would like providers and caregivers with lived experiences that are similar to their own. “I feel like it is different when you’ve got somebody that you can relate to compared to somebody that is just trying to teach you something that they read out of a book or that they haven’t lived or something,” said a 33-year-old man from Fresno County.
3. Meeting basic needs comes before addressing health concerns. Having a safe, stable place to live emerged as a priority over health for nearly every participant who is or had been homeless. “When you are on your own and you are homeless, you look for warmth, food, a shower, your primary needs. That is what you are focused on,” said a 68-year-old man in Alameda County. “You are constantly trying to meet those simple primary needs, and then you are neglecting the long-term needs — because your primary needs take priority.”
4. Need for fewer barriers to care. One in three participants emphasized the importance of preventive care to avoid falling into a crisis or seeing their condition deteriorate before being able to see a provider. Participants with substance use disorders said strict criteria prevent them from accessing needed recovery programs, while some felt compelled to exaggerate symptoms or misreport their condition to be prioritized. “Sometimes you aren’t homeless enough,” as one nonbinary person, age 24, from Humboldt County put it. Other participants said that long wait times and lack of follow-up have prevented them from getting the health care they need.
5. Desire for one-stop shopping. More than six in 10 participants said that being able to access multiple types of care and services in one location would provide a much-needed answer to the complex nature of their living circumstances and health needs. According to a 56-year-old man from Humboldt County, the ideal would be “either a mobile team or you can go to a facility . . . have counselors, mental health specialists, doctors, nurses who are trained to know how to help you, work with you, diagnose you, and then when you leave, you not only feel better, but you also want to give back.”
6. More help navigating the health care system. A majority of participants said they need readily accessible information about resources, and some said they only became aware of needed resources through “luck.” A female caregiver from Los Angeles shared that “the whole process of learning how to get him qualified for Medi-Cal, how to get enrolled in IHSS — that was a really difficult process for us. So, I think that this whole process would have been easier if there was some way to provide more support in navigating the system and informing you about all of the resources that are available.” Participants appreciated the critical role of community-based organization staff, whose help they rely on to connect them with the right care and support. As a 67-year-old man in Alameda County explained, “They’re already in the system, they know the ins and outs. I’m not trying to reinvent the wheel and run around, when I can go to someone that has the information that can guide me.” For many participants, the next best thing to more comprehensive care in one place is having one care manager they can rely on.
>> Read more about these key findings from the people CalAIM is trying to serve in the full CHCF report: In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care. Watch the video to hear more about their care. Read an interview with EVITARUS managing partner Shakari Byerly about the research project, Trusted Relationships Are Essential for Californians with Multiple Health and Social Needs.
Reflections from implementers: Providers and managed care plan leaders respond to the report
- Patient’s goals come first. Even well-intentioned providers from the health care and social service systems acknowledge they can occasionally fall into the trap of prioritizing their own goals (e.g., controlling diabetes or reducing readmissions) instead of asking the people they serve what would improve their health and well-being. “If the medical system could just understand that the patients’ needs are important, that their autonomy is important,” reflected Katelyn Taubman, a community health worker at Inland Housing Solutions. “If a client prioritizes a new bed, or getting into a housing unit, they’re not going to go to the doctor.” She stressed the importance
of “meeting the patient where they are.”
- Staff who reflect the community are essential to outreach and navigation. Community health workers have emerged as one of the most important elements of successful CalAIM initiatives, helping provide the system navigation that people with complex needs rely on. “Diversity is really important,” said Debbie Toth, CEO of Choice in Aging. “We heavily focus on having the people that we hire reflect the people that we serve, not just in race or ethnicity but also lived experience.”
- Training and other measures to reduce care manager turnover. While people with complex needs emphasized how traumatic it can be to have to “start over” with a new care manager, implementers stressed the importance of collectively addressing workforce challenges. They also highlighted the potential for data exchange improvements that can help prevent people from retelling traumatic events repeatedly, while reducing administrative workloads.
Sustainable partnerships build trust within the community. “The issue of trust is a problem across the board, starting with providers and managed care plans,” said Alex Fajardo, executive director of El Sol Neighborhood Educational Center. He added that managed care plans often see providers as vendors rather than as partners, which undermines collaboration. “A trusted relationship has to start at that level, built on mutual respect and a shared commitment to improving outcomes for the community. Without trust, it’s difficult to create the kind of integrated, people-centered systems that our communities need.”
>> Read more from providers and managed care plans in the full CHCF report: In Their Own Words: What Californians with Multiple Health and Social Needs Say About Their Care.
Other CalAIM Articles and Resources We Recommend
In this video, follow Shawn Baker's journey from 10 years of homelessness and repeated emergency room visits to stable housing and restored health. His success was made possible through an innovative cross-sector partnership in Orange County and CalAIM-funded services. Learn more about these partnerships on the CHCF website.
Enhanced Care Managers and Community Supports providers are invited to complete this survey as part of a statewide evaluation of the Providing Access and Transforming Health Initiative and the Community Supports Initiative. Make your voice heard! (UCLA Center for Health Policy Research)
2025 Behavioral Health Services Survey of over 2,289 community health center sites across 235 organizations in California. (California Primary Care Association)
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