Monica Arrowsmith has a new and important title for Roseville, Calif.-based Adventist Health. As executive director of CalAIM, she is overseeing all of Adventist’s programs related to the state’s multi-year Medicaid transformation effort, including a partnership with Emcara Health on Enhanced Care Management (ECM) services. Arrowsmith and Emcara CEO Eric Galvin recently spoke to Healthcare Innovation about their approach.
Emcara’s physician-led, in-home medical care solution increases access to timely and longitudinal treatment for a health plan’s most at-risk members. It uses predictive models to pinpoint members who are consistently high cost and can be positively impacted through additional home-based care and treatment. Emcara deploys integrated, multi-disciplinary in-home care teams that apply appropriate interventions and referrals based on a patient’s social, behavioral, and physical needs.
The three-year partnership combines Nashville-based Emcara Health’s advanced primary care model with Adventist Health’s clinical delivery resources to care for Medi-Cal members with the most complex care needs. As part of CalAIM’s Enhanced Care Management initiative, the partnership is intended to close care gaps for patients with the most complex care needs by addressing the social barriers, such as homelessness, that influence a patient’s health.
Emcara Health is deploying field-based care teams, consisting primarily of community health workers (CHWs), to meet patients on their terms, whether that’s at home, in a homeless encampment, or in the emergency department. Once engaged, CHWs conduct a social determinants of health assessment to understand the social impediments that may be impacting the patient’s health, such as access to food, stress, transportation and more. As part of the agreement, Emcara Health nurses and social workers are coordinating preventive care and clinical treatment through Adventist Health. Emcara is providing wrap-around support, including transitions of care, member and family assistance, and coordinating and referring patients to community and social support services.
Adventist has close to 20 hospitals and many clinics and skilled-nursing facilities across California. It has contracted with four Medicaid managed care organizations in the state and is working on contracts with several others, Arrowsmith said, adding that Adventist chose to work with Emcara because it already had experience in other markets and infrastructure built from that experience.
The State of California is rolling out the CalAIM services gradually. Last July, the three targeted populations that went live were homelessness. high utilizers of emergency departments, and people with substance use disorder or severe mental illness. Going live this month are populations associated with people who are either in long-term care or on the verge of having to go into long-term care. In July 2023 going live will be children and youth. In January 2024 it will be people who are transitioning from incarceration.
Adventist and Emcara have been working together for about seven months. In terms of evaluating the partnership with Emcara, Arrowsmith said, it is too early to have real outcome data. “We're looking at the volume of patients that we're receiving from the plans, the number of times that we are reaching out to different members, and how many of the members are agreeing to participate,” she said. “But we're also in the beginning stages of understanding how we look at outcomes. How do we take a person who had severe mental illness or substance use disorder and can we pull from other data sources to see that they are doing much better or whether or not they're on their medications?”
CalAIM gives both payers and delivery systems the motivation and some funding to take care of people who are particularly vulnerable and do it in a more creative way, Emcara CEO Eric Galvin said. “We're extremely excited about the Adventist partnership for a whole host of reasons, one of them being that this is what we do really well — it aligns with our mission. It's the right thing to do. But it also is an exciting sort of entrepreneurial adventure for our team.”
This type of vulnerable population tends not to have a primary care provider and as a result, the emergency room becomes their doctor's office. “What we try to do is try to keep them out of the emergency room for those types of activities other than true emergencies.” He said they also work on medication adherence and prescription fill rates. “If you don't have your own home address, it is difficult to keep up with medications, which leads to deterioration in that condition, which leads to you having an episode where you need to be hospitalized,” he added.
Galvin said Emcara has been re-imagining who to hire for the community health worker roles. “One of our colleagues, in particular, is a great example. She herself has experienced a lot of the kinds of social and other challenges that the people that we're trying to reach are. She knows where those homeless encampments are; she knows how they operate as a community and the hierarchies that exist. I got such an education on the realities of what homelessness looks like on the ground through folks like Lisa. The point is we've tried to re-imagine the kinds of people that could be really good at this and have credibility with those that we're trying to reach.”
One of the biggest challenge will be capturing the data, Arrowsmith added. “It's not data that's readily available. If I'm looking at utilization data, I know what's in our hospitals, but people don't only go to our hospitals. We were just on a call about getting in touch with health information exchanges to see what kind of data is available from them.”
There are other challenges with data, she added. “There are technical capabilities everywhere, but it's a matter of making it all work smoothly. We get data from the health plans. They send it to Emcara’s system, which they use, and their system sends it to us,” she explained. “We use Cerner, and that sends data to a big data repository, so there's just all of this mixing and matching. There are challenges, but they are not insurmountable.”