Community Based Organizations: Key Players for Health Plans to Maximize CalAIM Success.

Community Partnership Requirements under CalAIM

Community based organizations (CBOs) are an essential cornerstone for meeting the ambitious objectives of CalAIM (California Advancing and Innovating Medi-Cal), the five-year (2022-2027) statewide healthcare reform plan centered on an integrated and equitable, preventative and personalized whole-person care model.

CalAIM Requires Partnerships with Community Based Organizations

Medi-Cal, the largest state Medicaid program in the nation, insures about one-third of California’s 40 million residents and is the primary coverage source for low-income adults, children and those with disabilities. More than three-fourths of Medi-Cal beneficiaries participate in managed care plans (MCPs).

CalAIM requires Medi-Cal MCPs to partner with CBOs due to CBOs’ knowledge, experience and relationships with the communities and individuals they serve. Unique challenges and opportunities exist for MCPs who haven’t previously worked with CBOs or are new to doing so under CalAIM. Learn how MCPs can maximize the benefits of working with CBOs.

What is a Community Based Organization?

In the context of CalAIM, a community based organization (CBO) is defined as a public or private nonprofit representing or operating within a specific community (or significant community segments) and providing physical and mental health and/or social services to individuals in that community. CBO services may also include housing, nutrition and caregiver support.

Because of their community based role and access, CBOs are uniquely positioned to assist with the CalAIM objective of extending clinical and non-clinical support and services beyond healthcare settings to meet Medi-Cal members where they are – at home, in a shelter or on the street. Tracking the work and effectiveness of CBOs in this effort is critical to measuring CalAIM’s success.

MCP Challenges with CBO Partnerships

However, many CBOs – ranging in size from large-scale organizations to small, minimally staffed operations – have historically been more mission-driven than operationally focused and more attuned to delivering individual services than rigorously tracking their CBOs’ overall efforts, especially with respect to technology and systems or data integration and sharing. Many CBOs simply don’t have a sense of the MCP-oriented data requirements of CalAIM.

Given MCPs’ historic strengths in strategy, operations, and analytics – and their intrinsic interest in the success of CBOs relative to CalAIM – MCPs can assist CBOs in three critical areas: onboarding, operations, and reporting. By proactively assisting CBOs, MCPs may in turn reap significant long-term efficiency and cost savings, as well as better provide for the needs of their plan members.

MCPs can leverage their operational and analytical strengths by proactively assisting community based organizations (CBOs) in five crucial areas – contracting, billing, technology workflows, and reporting – to succeed as CalAIM partners.

Alleviating Contracting Challenges with CBOs

CalAIM requires MCPs to enter into contractual relationships with designated CBOs. However, many CBOs may be unfamiliar with such contracts. Rather than assuming CBOs will universally understand the intricacies of CalAIM-related contracting, MCPs should plan for the likely reality that CBOs will not be fully versed in contracting under CalAIM parameters. Once a CBO has been identified as a potential CalAIM resource, MCPs have many opportunities to support a CBO with the contracting phase.

1. Set expectations for what is required of a CBO to submit bills or claims to receive payment for services.
2. Provide CBOs with contracts that are clear and easy to understand.
3. Help CBOs develop required administrative processes to successfully adhere to contract terms. If a CBO lacks sufficient internal resources to fully meet a contract, the MCP should consider helping the CBO connect with external resources to build or procure this ability.
4. Ensure sufficient in-person interactions with a CBO for onboarding, including multilingual and culturally sensitive resources, to meet CBO needs.

Because most MCPs are historically oriented exclusively toward meeting the information needs of members and providers, this may require MCPs to establish CBO-specific resource teams. These teams may be part of existing provider services operations or standalone, based on the MCP’s operating model. It may also entail offering training opportunities for CBO employees.

Enhancing CBO Operations

As noted earlier, CBOs can vary widely in their size, mission, and communities served. Similarly, there can be wide variances in CBO experience with operations and finance. On the other hand, MCPs typically have a deep wealth of operational experience and resources to potentially leverage on behalf of their partner CBOs. The following are three areas in which MCPs can be of particular help to CBOs:

1. Billing. Many CBOs lack systems or operational experience with a claims-centric billing process. As a result, these CBOs often fail to complete claim submissions properly and thus do not get paid in a timely fashion. MCPs can assist CBOs by proactively educating them before they begin submitting claims, for example, by providing CBOs with “Claims 101” tutorials, technical support and coding counseling. Many CBOs rely on paper-based, labor-intensive manual processes for claims processing. MCPs can show them how to effectively shift from relying on outdated claims processing approaches.
2. Technology. Since technology is a common success factor for operational improvement, MCPs should strive to meet CBOs where they are and either work with a CBO’s existing technologies and/or provide technology resources that are easy to learn and use. MCPs might help the CBO understand the requirements and needs of inputs from the MCP side and plan for system and process controls to monitor and manage MCP/CBO data exchanges. There should be an emphasis on validating the quality of all data captured and uploaded.
3. Workflows. Base CBO-related workflows around MCP member needs. Ensure there is a process to gather and share sufficient and correct information on members to run them against program eligibility criteria. Develop a feedback loop so that the MCP is receiving sufficient data from the CBO to determine the CBO’s efficacy. Is there a self-referral process available for members? What prior authorization requirements are necessary? Is the referral process a closed loop? What is the appropriate next placement for a member once they are under the care of a CBO?

Improving Reporting on CBO Performance

The same technologies to improve CBO operations should also be able to capture proper information about CBO encounters for reporting against designated CalAIM metrics and key performance indicators. For example, as a baseline, a well-functioning CBO should be able to provide MCPs with accurate codes to show the services members are receiving – and whether members are part of specific population groups of focus. In turn, MCPs should be able to determine if these services are enhancing member outcomes per federal and state quality metrics.

To improve CBO program effectiveness, MCPs may need to help CBOs reframe their vision for care and focus more on service quality than merely service quantity. Many CBOs don’t have in place systems for reporting quality metrics. Gaining such data may require MCPs to educate CBOs on program effectiveness evaluation methodologies, assemble such data, and detail why it’s important.

In Conclusion

In coming years, CalAIM has the potential to dramatically improve the provision of preventive and whole-person care in California – provided that MCPs and CBOs can effectively work in concert toward achieving that goal. Given the typical unfamiliarity of many CBOs with care quality-related operations, metrics and reporting, it may be incumbent on MCPs to help CBOs with establishing internal processes to meet CalAIM standards.