Meeting Patient Needs Where They Need It Most

By Matt Phillion

California-based Adventist Health and value-based medical group Emcara Health have partnered recently to extend care into high-risk communities across the state. As part of the Enhanced Care Initiative from CalAIM (California Advancing and Innovating Medi-Cal), this partnership is intended to close care gaps for patients facing the most complex care needs by addressing barriers such as homelessness and other social determinants of health.

Shelly Trumbo, vice president of well-being at Adventist, explains that the care delivery model is intended to improve whole-person health and well-being for these populations.

“CalAIM’s goal is to advance the equitable way care is delivered,” says Trumbo. “In the U.S., we spend our massive healthcare budget primarily on two things: access to care and quality of care. These things matter. But we know that 80% of what makes people healthy has nothing to do with the care they get inside of a healthcare institution or clinic.”

Traditionally, organizations and providers haven’t been able to meaningfully access healthcare dollars to address social determinants of health, she explains.

“For many years, we’ve been holding what I call the equivalent of bake sales to build street teams and collaborations to help the people who fall through the cracks,” says Trumbo. “This opportunity helps us actually fix the broken systems by providing sustainable funding and infrastructure for community-based care, navigation, and outreach. Now we can build a system of care to sustain these services.”

For health systems, this is a game changer, Trumbo says.

“Enhanced care management (ECM) enables us to get out into the community,” she says. “For example, it’s not just referring the person to a food pantry. Instead, we can hire a staff person who can meet the patient where they are, drive them to access food, help them get to the DMV to get their ID needed for permanent housing and employment, take them to substance abuse treatment, help them get to dentist appointments—to fill in those gaps that help individuals get past those barriers to health.”

Much of community-based care involves navigation and case management for high-needs populations, endeavors that have long been reliant on shoestring budgets and grants. The organizations hope this state-specific plan can serve as a model for nationwide changes to how these patients interact with healthcare.

The program comes from Governor Gavin Newsom’s office and its efforts to stem the crisis around social determinants of health. The concept of ECM and community support enables the program to draw from Medi-Cal funding as it works to provide housing navigation, sober centers, transitional housing, medical respite housing—all of the things that can help people get back on their feet.

“The complexity of standing up this new service line inside a traditional healthcare system is no small feat—you’ve got to set up entire revenue cycles, billing codes, link it to the electronic medical record,” says Trumbo. “It’s a huge amount of work and not as easy as flipping a switch. But it’s so meaningful to be able to consider using our healthcare dollars towards it.”

An ecosystem of care within communities

As the program becomes a reality, healthcare workers have been excited about the ability to incentivize ecosystem development within communities, Trumbo says.

“In each community there are nonprofits, community-based organizations, and others who are able to provide services” to community members, she says. But with this program, these groups have a reason to sit together and discuss how they’ll partner “in such a way that it is a true collaboration and customized for each individual community.”

For healthcare organizations, this interconnectivity is important. “As anchor institutions, hospitals and healthcare systems have heavy influence in communities, but to really support well-being transformation, solutions must empower and strengthen all of the community partners,” Trumbo says. “CalAIM funding can be new revenue streams for other nonprofits in the community, for example.”

Healthcare organizations can’t solve every problem, so there needs to be a shift to come together and create an ecosystem where each community organization, nonprofit, and health system is able to do what they do best and partner with other organizations to make it all work.

“In each community, we are uniquely attempting to collaborate in meaningful ways with partners,” says Trumbo. “If there’s a nonprofit providing outstanding medical respite or housing navigation—two examples of CalAIM reimbursable community supports—we want to support and empower them through partnership and collaboration.”

This is where Emcara Health comes into play. “Because of the size of our footprint, the number of members who are eligible for these services is significant. To stand up a service line of that magnitude that quickly, we looked for a partner who is already providing community-based care navigation in an effective way,” says Trumbo. “Emcara already have the capacity to recruit, train, mentor, and create a work culture that supports excellent outcomes for these services.”

Lifting all boats

There has been significant advancement toward a future where healthcare is working toward more value-based arrangements, Trumbo notes.

“For healthcare, if you’re strictly working on a fee-for-service basis, reducing utilization isn’t financially incentivized,” she says.

The environment as it stands doesn’t necessarily promote lowering utilization the way a value-based system would. In addition, the individuals eligible for the sort of program CalAIM is building are often among the top 5% of utilizers—they are frequently in need of healthcare services, emergency department (ED) visits, or inpatient stays that go past a reasonable length of time. “Taking this into account, you begin to see how preventing excess utilization and ensuring a person is getting the care and interventions they really need helps improve their overall health and well-being, while lowering overall cost of care.”

This is not a new concept for California. An initiative has been operating for roughly five years focusing on whole-person care, which essentially went on to become CalAIM. The first sites acting as pilots for whole-person care launched in January 2022, and those receiving care through the program transitioned to CalAIM.

“Thinking back to the multisector ecosystem design, whole-person care taught us more than anything else that healthcare can’t solve the challenges we’re facing alone,” says Trumbo. Specifically, she points to multisector case conferencing, in which agencies collectively support individual patients.

For example, in examining how agencies could convene in a way that enabled them to sit across the table from each other and improve their systems, Trumbo’s team decided to follow one individual who was using many of those systems: mental health, police encounters, jail stays, ED visits, and behavioral health. They looked at all the services each system was providing and how they could wrap those services around that individual. What they found was that he had been assigned 15 case managers, as each interaction would provide one. But the case managers didn’t know their counterparts existed and weren’t working together.

“This costs money, it’s futile, and the situation was escalating,” says Trumbo. “We asked, ‘How can we work together to create a multisector case conferencing plan that helps us really support individuals in the community in a different way?’ That laid the groundwork for us.”

Right now, the program faces the practical challenge of establishing funding mechanisms. Successful implementation also requires structuring work in different ways.

“The biggest challenge right now is building the infrastructure with managed care plans, the workflows and processes within health systems and with community partners. We’re working as fast as we can to get some of those revenue sources and startup investments,” says Trumbo. “We’ve got to make it through the trial period and show that it’s viable—to show that we can stand it up, that it is financially sustainable, and that it’s scalable.”

An estimated 300,000–400,000 Californians are eligible for CalAIM services, Trumbo says. “In a perfect world, success would mean that 350,000 human beings receive the support and care they need to transform their health and well-being,” she says. “That’s going to take a lot of partnering, a lot of trust across agencies to get it done. But if we can prove it is effective and sustainable, I believe it’s a model that can be shared across the country, making care in the United States more equitable and transformational for all.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at