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
Here is one piece of good news to kick off the year: CalAIM’s transitional rent program (PDF) is now live! Starting January 1, plans are now required to cover up to six months of rental assistance for Medi-Cal members facing or at risk of homelessness who meet specific criteria — a critical step toward improving the health and well-being of vulnerable Californians. ICYMI: A new toolkit from a cross-sector group of implementers includes a step-by-step guide frontline staff and plans can use to complete Housing Support Plans that will allow their residents and members to access the transitional rent benefit.
Highlights
New reports: The crucial role of counties in California’s health system
CHCF has published two major new reports on how counties deliver and manage many of the state’s most essential health care services, from health care access and public health to behavioral health.
Toolkit: This DHCS resource offers guidance for creating successful community care hubs
The California Department of Health Care Services has released a new tool with guidance for the growing number of community care hubs that fill administrative gaps between plans and CBOs delivering CalAIM services.
Article: How hospital-based Enhanced Care Management helps both patients and hospitals
Hospitals, especially emergency departments, frequently see patients with complex needs. So hospitals providing ECM can improve patients’ health and lower hospital costs.
New reports: The crucial role of counties in California’s health system
While state government is often in the headlines for developing health care policies, California’s 58 counties are responsible for delivering many of the state’s most essential health care services and often have a role in financing them as well.
Counties serve as the foundation of mental health and substance use care for people with serious behavioral health conditions and provide safety-net services for millions of people with low income. Through their public health departments, counties also run laboratories and lead programs that protect the health of entire populations.
Since 2004, CHCF has periodically published reports on the crucial role California’s counties play in the health care ecosystem — and how local agencies are organizing themselves to manage their evolving workload and the needs of their communities.
The two most recent reports in this series were published earlier this month, offering the latest on county governance structures, pilot programs, and funding streams — for both health care and public health programs, as well as fast-expanding behavioral health systems.
>>Read CHCF’s two new county reports:
- The Crucial Role of Counties in the Health Care and Public Health of Californians (PDF)
- The Crucial Role of Counties in the Behavioral Health of Californians (PDF)
>>A companion issue brief summarizes funding sources counties are relying on to deliver new behavioral health services:
Toolkit: This DHCS resource offers guidance for creating successful community care hubs
CalAIM is advancing partnerships between managed care plans and community-based organizations (CBOs) to support more coordinated, comprehensive care — particularly for health-related social needs. As these partnerships grow, new organizations called community care hubs are emerging to address operational challenges. These hubs help meet growing demand by providing centralized contracting, quality oversight, and administrative support, allowing CBOs and providers to focus on delivering care and services.
Earlier this month, the Department of Health Care Resources (DHCS) released a new toolkit aimed at strengthening partnerships between plans and hubs. The toolkit describes key hub functions and highlights successful models operating in Los Angeles and across Northern California. It also offers practical guidance on contracting, subcontracting, and compliance for plans and CBOs.
>> Check out these DHCS resources:
- The MCP-Hub Toolkit: A Resource for MCPs and CalAIM Providers.
- A recent DHCS webinar offered more details on the toolkit and program-specific considerations for ECM, Community Supports, community health workers, and doula services. Watch the recording.
>> More background on community care hubs is available in this 2024 CHCF report, Exploring Emerging Medi-Cal Community Care Hubs.
Article: How hospital-based ECM helps both patients and hospitals
Cuc Dao’s health issues began in early 2022, when she suffered a series of strokes so severe she had to be airlifted from her home in rural Ukiah to Sacramento. Dao, who was 53 at the time, spent a month in the hospital before returning home to face an even more daunting challenge: relearning how to walk, talk, and do even the simplest tasks.
That’s when Tony Marsh appeared, a care manager with Adventist Health who seemed to know everything about her situation — and who was eager to help, from scheduling physical therapy and medical appointments to ensuring she had access to her prescriptions.
This seamless, coordinated care — which proved critical to Dao’s recovery — didn’t happen by accident. As described in a new CHCF article, Adventist is an outlier among hospitals and developed its own team of ECM providers. Marsh and his team’s offices are adjacent to the emergency department, and the hospital’s software automatically flags patients who qualify for ECM services when they are admitted. The result: Early interventions, backed up by coordinated care like that offered to Dao, helping Adventist save millions of dollars each year in health care expenditures.
“As a lead care manager, we see the difference we make in people’s lives all the time,” said Marsh. “But it’s also nice to see the data.”
When Dao’s husband died unexpectedly shortly after her strokes and Dao had to move in with family in Bakersfield — 400 miles away — Adventist connected her with yet another care manager, who picked up right where Marsh left off. Several years later, Dao has avoided returning to the hospital and is managing the conditions that led to her strokes. She can now see her doctors, make appointments, and call for Ubers by herself.
She thinks she’s not too far away from the day she’ll graduate from the ECM program. “I’ve had a lot of help and encouragement,” she says. “Without it, I don’t know where I would be.”
>> Read the CHCF article on the success of Adventist’s ECM program:
Other CalAIM Articles and Resources We Recommend
- Street Medicine: A Critical Pathway for Behavioral Health in California (CHCF)
IHSS ECM Toolkit (Archstone Foundation)
This toolkit was designed to help county In-Home Supportive Services (IHSS) social workers and public authority staff refer eligible IHSS recipients to Enhanced Care Management.
- Community Supports Pricing Resource (PDF) (DHCS)
- CalAIM Community Supports — Managed Care Plan Elections (PDF) (updated December 2025) (DHCS)
- CalAIM Enhanced Care Management Enrollment by County and Managed Care Plan – 2024 Q2 - 2025 Q1 (PDF) (California Health Policy Strategies)
- CalAIM Community Supports: Utilization by County and Managed Care Plan – 2024 Q2 - 2025 Q1 (PDF) (California Health Policy Strategies)
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