This pragmatic, cluster-randomized trial will evaluate whether a comprehensive CalAIM-aligned care model consisting of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential care coordination improves population health outcomes among high-risk Medi-Cal managed care members in California compared with usual CalAIM service delivery. The intervention is intended to improve continuity of care after discharge, reduce potentially avoidable utilization, increase successful linkage to outpatient and social supports, and improve community tenure and patient-reported outcomes.
Adult Medi-Cal managed care member in California.
Identified as high-risk for poor outcomes based on plan stratification or qualifying CalAIM criteria.
Eligible for ECM and at least one of the following: Transitional Care Services, Community Supports related to post-acute recovery, housing/residential stabilization, or nursing facility transition/diversion.
Recent discharge or active transition from hospital, emergency department, skilled nursing facility, post-acute facility, recuperative care, assisted living, residential behavioral health setting, or other qualifying level-of-care transition.
Enrollment in hospice or expected survival less than 6 months at the time of the index episode.
Long-term custodial institutional placement without an anticipated community transition plan.
Current incarceration or detention is preventing intervention delivery.
Previous enrollment in this study during the same observation window.