CalAIM at HPSM

Medi-Cal members must fall into one of the following populations of focus to be eligible for services:

• Adults (21 or older) who are:
  • Experiencing homelessness AND
  • Have at least one complex physical, behavioral, or developmental need with inability to self-manage for whom coordination of services would likely result in improved health outcomes and/or decreased utilization of high-cost services 
• Families or unaccompanied children/youth who:
  • Are experiencing homelessness or housing insecurity OR
  • Are sharing housing with other persons (i.e. couch surfing) due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, camping grounds or shelter.
• Adults (21 or older) with serious mental health and/or substance use disorders (SUD) with:
  • Serious mental health and/or SUD needs who meet the eligibility criteria for participation in, or are obtaining services through one or more of Specialty Mental Health Services (SMHS) and/or Drug Medi-Cal Organization Delivery System (DMC-ODS) AND
  • At least one complex social risk factor influencing health AND
  • Meet one or more of the following criteria:
    • Pregnant or postpartum OR two emergency department visits or hospital stays for SUD in the last 12 months OR high risk for overdose, suicide or institutionalization OR using crisis and urgent services as primary source of care.
• Children and youth with serious mental health and/or SUD needs who meet the eligibility criteria for participation in, or are obtaining services through one or more of Specialty Mental Health Services (SMHS) and/or Drug Medi-Cal Organization Delivery System (DMC-ODS).
  

• Adults (21 or older) living in the community at risk for long term care (LTC) institutionalization:
  • Presence of qualifying factors for long term care currently or imminent without wrap around care OR who require lower-acuity skilled nursing AND
  • Actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to, needing assistance with ADL, access to food, access to stable housing, living alone) AND
  • Able to reside continuously in the community with wraparound supports. 

• Adults (21 or older) at risk for avoidable hospital or ED utilization (formerly high utilizers) with:
  • Five or more emergency department visits within a 6-month period that could have been avoided AND/OR
  • Three or more unplanned hospital or short-term skilled nursing stays in the last 6months.
• Children and youth at risk for avoidable hospital or ED utilization with:
  • Three or more ED visits in a 12-month period that could have been avoided AND/OR
  • Two or more unplanned hospital and/or short-term skilled nursing stays in a 12-month period
• Adults (21 or older) nursing facility residents transitioning to the community who are interested in moving out of the institution; are likely candidates to do so successfully, and are able to reside continuously in the community.
  • An example of an eligible member is one who has:
    • Been a SNF resident at least 60 days.
    • Has cognitive and decision-making capacity or has legal decisionmaker.
    • Has or is able to secure caregiver support or eligible for IHSS hours. Has Activities of Daily Living (ADL) and/or Instrumental Activities of Daily Living (IADL) needs that can be managed in the community with In Home Support Services (IHSS) or caregiver support and improved functional status while in skilled nursing facility.
• Children and youth enrolled in CCS Whole Child Model with additional needs beyond the CCS condition:
  • Enrolled in CCS WCM AND
  • Are experiencing at least one complex social factor influencing their health
• Children and youth involved in child welfare who meet one or more of the following conditions:
  • Are under age 21 and are currently receiving foster care in California or previously received foster care in California or another state within the last 12 months
  • Have aged out of foster care up to age 26 if they were in foster care on their 18th birthday or later in California or another state
  • Are under age 18 and eligible for or in  California’s Adoption Assistance Program
  • Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months
• Birth Equity (Adults and Youth):
  • Adults and Youth who are pregnant OR postpartum (through a 12 month period), AND
  • Are subject to racial or ethnic disparities.

Pregnant and postpartum individuals can receive ECM if they qualify under any of the ECM Populations of Focus.

• Adults and Youth transitioning from incarceration.
  • Adults who:
    • Are transitioning from a correctional facility (e.g., prison, jail, or youth correctional facility) or transitioned from correctional facility within the past 12 months; AND
    • Have at least one of the following conditions (See Appendix C for definitions):
      • Mental illness;
      • SUD;
      • Chronic Condition/Significant Non-Chronic Clinical Condition;
      • Intellectual or Developmental Disability (I/DD);
      • Traumatic Brain Injury (TBI);
      • HIV/AIDS;
      • Pregnant or Postpartum.
    • Children and Youth who are transitioning from a youth correctional facility or transitioned from being in a youth correctional facility within the past 12 months.

Members eligible for ECM services may also be good candidates for a 1915(c) waiver program; however they cannot be enrolled in ECM and a 1915(c) waiver program at the same time. For detailed information and eligibility criteria for HPSM’s populations of focus please see DHCS links APL 21-012, APL attachment and DHCS ECM Policy Guide.