Through Enhanced Care Management (ECM), CalAIM provides whole-person, interdisciplinary care for individuals with complex medical and social needs. The program serves individuals undergoing life transitions and difficulty with developing and maintaining a healthy life routine. TPF’s team of Community Health Workers and Lead Care Managers coordinate care, provide health resources, and ensure access to necessary healthcare services.
Problem Statement: Individuals with complex medical and social needs, particularly those from historically underserved communities, often face significant barriers in accessing coordinated care, housing support, and necessary health services. This includes people experiencing homelessness, those at risk of avoidable hospital visits, and individuals dealing with behavioral health challenges. Traditional healthcare systems frequently fail to address the nonclinical factors that contribute to poor health outcomes, such as housing instability, limited access to social support, and a lack of community-based interventions. Without a comprehensive care management approach, these individuals are left navigating fragmented systems that exacerbate their health disparities and prevent long-term wellness.
Solution Statement: The Therapeutic Play Foundation’s CalAIM Program, through its Enhanced Care Management (ECM) model, provides a whole-person, interdisciplinary approach to care that addresses both clinical and nonclinical needs. By integrating Community Health Workers, the program offers personalized care coordination, housing support, and advocacy for healthcare access. The standalone Community Health Worker benefit empowers individuals to navigate complex healthcare systems, secure stable housing, and connect with community-based resources. TPF’s ECM model emphasizes culturally competent, trauma-informed care, and offers flexible services in-home, virtually, or at community partner sites. This approach ensures that underserved populations, including those experiencing homelessness or housing instability, receive the comprehensive support needed to improve their overall well-being and reduce reliance on emergency services.
Program Goal: Provide whole-person, interdisciplinary care for underserved populations with complex medical and social needs through the Enhanced Care Management (ECM) model. The program addresses both clinical and nonclinical factors affecting health, such as housing instability and social determinants of health. By integrating Community Health Workers and delivering culturally competent, trauma-informed care, the program seeks to improve overall well-being, reduce reliance on emergency services, and support individuals in securing long-term, sustainable health outcomes.
Eligibility Requirements for CalAIM Program (Program #3):
- Enhanced Care Management (ECM)
- Target Population:
- Individuals with complex physical, behavioral health, or social needs.
- Medi-Cal beneficiaries who are high utilizers of health systems or at risk of adverse health outcomes.
- People experiencing homelessness or housing instability.
- Individuals with severe mental illness or substance use disorders.
- Those transitioning from institutional settings or dealing with complex chronic conditions.
- Eligibility Criteria:
- Must be a Medi-Cal beneficiary.
- Be part of a vulnerable population requiring enhanced care coordination to address nonclinical factors like housing, food security, and access to community-based services.
- Community Health Worker (CHW) Standalone Benefit
- Target Population:
- Individuals needing support in navigating healthcare systems or accessing nonclinical services.
- Medi-Cal beneficiaries who could benefit from education and advocacy, particularly in managing chronic conditions, securing stable housing, or connecting with community resources.
- Eligibility Criteria:
- Must be a Medi-Cal beneficiary.
- Require assistance with care navigation, accessing healthcare, or securing social services.
- Community Supports (In-Lieu of Services)
- Target Population:
- Medi-Cal beneficiaries at risk of institutionalization or needing interventions to prevent avoidable emergency services.
- Individuals who could benefit from services addressing social determinants of health, such as housing support or medically tailored nutrition.
- Eligibility Criteria:
- Must be a Medi-Cal beneficiary.
- Require services that prevent the need for higher-cost institutional or emergency care, such as housing assistance, recovery services, or respite care.
This structure ensures that TPF’s CalAIM Program supports the unique needs of underserved populations by providing comprehensive care that addresses both their medical and social determinants of health.
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