RamaOnHealthcare December 9, 2022

CalAIM is a multi-year initiative to improve the quality of care provided to Medi-Cal members by implementing a broad delivery system, program, and payment reform across the Medi-Cal program.

Karen Lapoce, Senior Director of Government Solutions at ZeOmega

Karen Lapoce, Senior Director of Government Solutions at ZeOmega

Today, RamaOnHealthcare talks with Karen Iapoce, Senior Director of Government Solutions at ZeOmega, about the CalAIM initiative. ZeOmega empowers health plans and other risk-bearing organizations with the industry’s leading technology for simplifying population health management. As an expert in her field, Karen is keeping a close eye on CalAIM’s progress and is helping health plans across the nation successfully bridge the initiative’s concepts to their geographical location and business structure.

RamaOnHealthcare (ROH): Why are all states — not just California — staring closely at the CalAIM initiative right now?

Karen Iapoce (KI): It is essential to start by level setting and understanding the depth and breadth of the CalAIM initiative. By their definition, California Advancing and Innovating Medi-Cal (CalAIM) is a multi-year initiative to improve the quality of care provided to Medi-Cal members by implementing a broad delivery system, program, and payment reform across the Medi-Cal program. The major components of CalAIM are built upon the lessons learned from various pilots, such as Whole-Person Care, Health Homes Programs, and Coordinated Care Initiative.

Essentially, the goal of CalAIM is to align the elements of Medi-Cal into a system that is standardized, simplified, and focused on helping enrollees live healthier lives. The initiative is to move toward a population-health approach that will focus on prevention and whole-person care. It touches an enrollee from birth to the end of life.

California has the largest population of any state. With over 40 million people, it accounts for 12% of the total U.S.A. population. Approximately one-third of Californians rely on California’s Medicaid program, called Medi-Cal. As of 2021, Medi-Cal covered nearly 14 million people.

Along with the substantial financial investment and the commitment/participation of the network of health and community organizations, the initiative will work with other Department of Health Care Services (DHCS) initiatives, as well as items in the state budget. This is a collaborative initiative, and it requires all parties, especially servicing providers and plans, to track these items/initiatives alongside CalAIM to understand how each works separately and together. There are a lot of moving parts and many players. Success demands a high level of information sharing, silo destruction, and a lot of infrastructure work.

The initiative is about breaking down barriers that block access to quality and timely care, providing aid to the most vulnerable residents, and offering more equitable programs. This mission is similar in all states, as we recognize the overall impact of social determinants of health and health disparities. To achieve the best health outcomes possible, non-medical needs must be identified, addressed, and met. Healthcare cannot focus only on physical health. Behavioral health must also be addressed in whole-person, integrated care plans.

The initiative is about breaking down barriers that block access to quality and timely care, providing aid to the most vulnerable residents, and offering more equitable programs. This mission is similar in all states, as we recognize the overall impact of social determinants of health and health disparities.

Knowing the complexity of the initiative and the anticipated positive outcome on individuals, families, communities, and the overall population, warrants other states, providers, payers, and servicing entities to keep an eye on what is working well and what initiatives they can adopt. Changes from the CalAIM initiative will span a multi-year period, with the first reforms already underway, effective as of January 1, 2022. Subsequent reforms will be phased in through 2027.

Allowing other states to scrutinize the progress of CalAIM — questioning what worked well, the initiative’s effectiveness, and if similar programs can be applied outside of California — we may find that California will define the road map for other states and drive widespread national policy change.

Allowing other states to scrutinize the progress of CalAIM — questioning what worked well, the initiative’s effectiveness, and if similar programs can be applied outside of California — we may find that California will define the road map for other states and drive widespread national policy change.

ROH: What functionality are health plans currently seeking and needing to support the CalAIM initiative?

KI: Health plans are looking for a system that can provide whole-person and whole-community care. This requires collaboration, coordination, and data sharing to drive actions.

To meet CalAIM’s requirements for both the state and county, plans will need to implement a healthcare enterprise management system that is nimble and flexible. The platform should seamlessly manage:

  • Government and state waivers (Medi-Cal)
  • Seniors and individuals living with disabilities
  • Children with complex medical conditions
  • The growing number of justice-involved populations who have significant clinical needs
  • The incorporation of SDOH data into care plans

To meet CalAIM’s requirements for both the state and county, plans will need to implement a healthcare enterprise management system that is nimble and flexible. The platform should seamlessly manage….

ROH: How do ZeOmega’s solutions support the CalAIM initiative and programs?

KI: This is a great question. ZeOmega’s industry-leading population health management platform (PHM), Jiva, helps payers meet CalAIM challenges by encompassing the core of what CalAIM strives to accomplish. It can be configured quickly and easily to meet any specialized needs that California counties may have, enabling maximum flexibility of use. Jiva is specifically designed to bring integrated, whole-person health management to life, managing all PHM needs within a single application. We’ve made sure it simplifies complex workflow, all while meeting regulatory and reporting requirements and keeping the goals of CalAIM core to the workflow.

To be specific, CalAIM describes Enhanced Care Management and In Lieu of Services (ILOS) like this:

CalAIM has established an Enhanced Care Management (ECM) benefit, which provides intensive whole-person care management and coordination to address the clinical and non-clinical needs of Medi-Cal members with complex needs. ECM will ensure that enrollees with complex needs are identified and engaged by someone who understands their goals, develops a plan in partnership with them and their providers, and actively connects them with the clinical and non-clinical services and resources that help them meet those goals.

CalAIM has also established an In Lieu of Services (ILOS) community supports program, which provides cost-effective, health-supporting services the goal is for the covered services to reduce hospitalization and institutionalization, reduce cost, and address underlying drivers of poor health. DHCS will allow 14 ILOS categories, including housing transition and navigation services, respite care, day habilitation programs, and nursing facility transition support to an assisted living facility or a home.

Jiva directly supports these initiatives by providing:

  • A comprehensive assessment and Care Management planning solution
  • Transition of Care (TOC) workflows
  • Rules to decrease disruption of service delivery
  • Interoperability and predictive analytics
  • A cutting-edge Social Determinants of Health (SDOH) solution (including analytics, reports, automated workflows, and the ability to connect with Community-Based Resource Organizations [CBROs] and show a closed-loop referral process)
  • The ability to manage all lines of business: Medicaid, Dual Special Needs Plans (DSNPs), Long-Term Services and Supports (LTSS), and Medicare
  • A layered view of social and clinical risks
  • A robust mobility application to work assessments online or offline
  • Specific workflows that meet all age brackets in all setting types
  • Comprehensive member-engagement workflows
  • Tracking and reporting on key CalAIM metrics

ROH: What have you learned from your clients who are working hard to meet the CalAIM initiatives in time?

KI: I’ve learned our California clients are extremely committed to the initiative and truly want to enhance services for their members. They are a fabulous group of talented, innovative thinkers who recognize the positive outcomes CalAIM may produce. They welcome change.

Our goal at ZeOmega is to support our clients’ journey by providing a 360-degree view of their members and populations on one, integrated platform. Jiva does this. Its dashboard data gives indications that allow hypotheses to be tested through inquiry and visualization. The actionable results drive evidence-based strategy and measurable interventions using the intelligent orchestration of a rules-based engine that automatically drives the next-best-practice workflows. It helps close gaps in physical, behavioral, and social care — all while reducing health disparity. Jiva also lets you measure the success of programs pre- and post-implementation, a key benefit to improving business.

Our clients are looking for automated workflows, easy integration with other entities, and a way to eliminate siloed views of a member. Jiva provides all this and more. It’s a unique enterprise management system that spotlights meaningful touchpoints within the care spectrum to foster trust and engagement — a system that will bridge silos across physical, behavioral, and social determinants of health to improve health outcomes while decreasing inappropriate utilization and/or duplication of services.

About Karen Iapoce

Karen Iapoce, Senior Director of Government Solutions at ZeOmega, has 30+ years of experience in strategic healthcare. Over the years, her titles have ranged from RN to Senior VP of Clinical Operations and Director of Government Solutions. Karen is a clinical leader, trainer, and liaison experienced in driving innovations in quality, products, metrics, revenue, and cost. She has expertise in Medicaid, Medicare, Social Determinants of Health, and federal/state regulations and their application within payer/provider environments.

 
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