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Edward El is an unhoused particular person that's at present staying on the Radisson Lodge on Edes Ave. in Oakland, which is at present occupied by unhoused people and caseworkers as a part of Mission Roomkey on Feb. 9, 2022. Photograph by Martin do Nascimento, CalMatters
By Kristin Hwang | CalMatters
At 66, Edward El has a brand new lease on life — actually. In two weeks, he’ll transfer into his personal residence in Berkeley after spending the higher a part of the previous 16 years homeless.
Years in the past, a again harm and pinched nerves in his legs made standing and strolling painful, and he was laid off from his building job. He ended up in “shelter after shelter after shelter.”
However 9 months in the past, El moved into considered one of 12 Mission Roomkey shelters in Alameda County designed to scale back COVID-19 among the many homeless inhabitants. He was related with a housing navigator, a counselor and medical workers. They helped El apply for reasonably priced housing and rental help vouchers, and coordinated with landlords who would give homeless renters an opportunity. Now he’ll pay a fraction of the fee to stay in an space the place one-bedroom residences usually exceed $3,000 monthly.
The crew additionally made positive that El was enrolled in Medi-Cal and had transportation to his physician’s appointments. He stated he couldn’t have navigated the array of complicated programs if it weren’t for his new case administration crew. “I’m pleased. They knew about applications that I didn’t find out about that allowed me to get a spot,” he stated.
Intensive case administration like that is an instance of the formidable, sweeping adjustments California made to Medi-Cal starting in January beneath an initiative it’s calling CalAIM, or California Advancing and Innovating Medi-Cal.
Medi-Cal presents medical insurance coverage to low-income Californians, serving as a lifeline for almost half of the state’s youngsters, one in 5 adults and a couple of million seniors and other people with disabilities. However this system is inefficient: Greater than half of Medi-Cal’s roughly $133 billion annual price range is spent on simply 5% of this system’s highest-needs people — individuals with a number of complicated well being issues compounded by homelessness, poverty, substance abuse, psychological sickness or incarceration, in accordance with the Division of Well being Care Companies.
Over the subsequent 5 years, the aim of CalAIM is to deal with the upstream drivers of deteriorating well being — issues like meals insecurity and housing instability — in an effort to scale back expensive emergency division visits, hospitalizations and nursing homestays. This system redesign relies on “whole-person care” rules, which assist individuals keep away from conditions that worsen their bodily and psychological well being.
“This was designed on the county stage to establish very high-risk populations — oftentimes individuals who had been coming to the emergency room 5 to 10 instances a month,” stated Erica Murray, president and CEO of the California Affiliation of Public Hospitals and Well being Methods.
In his January price range, Gov. Gavin Newsom proposed $8 billion over 5 years to implement this system, about 6% of Medi-Cal’s complete price range. Included are momentary funds to managed care plans to supply enhanced case administration and different providers.
These so-called social determinants of well being haven't been traditionally lined by medical insurance like Medi-Cal. But they've an outsized impression on individuals who usually wrestle with financial instability, poor diet, discrimination, violence and disproportionate publicity to polluted air and water.
“One in all my sufferers calls it social deterrents to well being,” stated Alameda County Medical Director Dr. Kathleen Clanon.
No different state has mounted such a complete program that wraps in so many components. The dimensions is unprecedented, too: Medi-Cal offers medical insurance for greater than 13 million individuals.
“It is a huge deal. Not solely is California taking the lead but in addition setting a precedent for probably different states to comply with it,” stated Anthony Wright, government director of Well being Entry California, a shopper advocate group.
Pilot applications in 25 counties helped get CalAIM off the bottom. Roughly 108,000 Medi-Cal sufferers had been enrolled in county pilots and 15,000 in managed care pilots throughout a two-year interval, in accordance with an early evaluation by UCLA researchers. On account of the success, federal officers granted a waiver permitting CalAIM to maneuver ahead for the subsequent 5 years.
In Placer County, David Norris, 67, was one of many sufferers who benefited from the experimental applications.
Norris ended up in a homeless shelter after his mom, whom he was a long-term caregiver for, died. He earns $900 a month in Social Safety and retirement, but it surely’s not sufficient for hire and residing bills. In April, an contaminated foot wound unfold to the bone and price Norris his left leg. One other an infection resulted in additional journeys to the ER and subsequent surgical procedures. A number of months later, a struggle on the shelter led to a shove, a fall and a damaged proper leg.
His caseworker, Todd Perbetsky, helped him enroll in Medi-Cal, discover a nursing house to recuperate in and apply for a housing voucher. He’s now serving to Norris discover everlasting housing after leaving the nursing house.
“These are undoubtedly individuals which can be falling by way of the cracks,” Perbetsky stated. “They might not meet the standards of some applications. They might want linkage to providers. They'll have tons of obstacles to even getting their CalFresh turned on or different advantages they qualify for.”
Norris known as Perbetsky a “hell of a godsend. Should you don’t know the ins and outs, you simply get spit out. You get completely no assist in any respect. That’s the place Todd…helps me and other people like me navigate the waters and get all squared away.”
A Byzantine system
Wraparound providers aren’t new, however they haven’t at all times been simple to entry nor have they been immediately related to medical care. Stroll by way of the improper door and also you won't get any assist in any respect.
A homeless affected person who suffers from habit and psychological well being points and has diabetes must method three completely different county departments and a health care provider as a way to get all of their wants addressed, and even then they’re more likely to get misplaced within the system.
“It’s a little bit bit like when you wanted to get substances for a meal and as a substitute of simply going to the grocery store, you needed to go to completely different shops to get your proteins and your fruits and your grains and your greens. And at these shops, you needed to pay with completely different playing cards and navigate completely different guidelines about what you would purchase,” stated Melora Simon, a senior strategist on the California Well being Care Basis.
This fragmentation ceaselessly causes obstacles to well being care and is without doubt one of the main causes the Division of Well being Care Companies is concentrated on reforming Medi-Cal beneath CalAIM.
One such barrier is ensuring sufferers don’t get misplaced between programs that don’t historically speak to 1 one other.
Clanon, who additionally works as a doctor in Alameda County, stated a couple of years in the past a pregnant, HIV-positive affected person wanted to start HIV therapy however had left the same old encampment she stayed in and couldn’t be discovered. A nurse spent greater than an hour calling native emergency departments, homeless shelters and case managers to see if anybody had seen the affected person, with no luck.
Had the system been built-in, Clanon’s affected person would have been flagged as needing vital medical care any time she entered a homeless shelter, emergency division, substance abuse heart or psychological well being facility.
“CalAIM is making an attempt to repair the issue of disparate programs of care each amongst and between completely different counties and amongst and between completely different elements of the healthcare system,” stated Diana Douglas, a well being coverage knowledgeable with Well being Entry California.
Accountability and lacking items
Since 2016, California has devoted greater than $3 billion in state and federal funds to experiment with doing simply that.
4 years after launch, the pilots demonstrated “substantial proof” of improved follow-up after hospitalization for psychological sickness, elevated participation in substance abuse therapy and decreased use of emergency providers, amongst different metrics, in accordance with the UCLA evaluation.
In Contra Costa County, greater than 12,000 sufferers have enrolled within the pilot yearly, and the county well being division employed greater than 100 public well being nurses, psychological well being specialists, group well being employees, homeless service specialists, substance abuse specialists and social employees to offer coordinated case administration.
“Most of them had been varieties of positions that existed within the county earlier than, however they had been very siloed,” stated Emily Parmenter, the pilot’s program supervisor at Contra Costa County Well being Companies. “So we introduced all of them collectively in these multidisciplinary groups the place they'd a wealth of expertise…and had been capable of present case consultations throughout divisions.”
Medi-Cal sufferers who enrolled within the Contra Costa pilot skilled medical emergencies much less ceaselessly than non-enrolled sufferers.
“We discovered that after being concerned in this system for a 12 months, our hospital admission charges decreased by 25%…and our (emergency division) charges had been 14% decrease in comparison with the management group,” Parmenter stated.
UCLA researcher Nadereh Pourat, who performed the pilot analysis, stated her crew has simply begun to investigate the impression on particular well being circumstances, comparable to blood stress and congestive coronary heart failure, in addition to cost-effectiveness.
Regardless of their promise — or maybe due to it — advocates say the transition from pilot applications to CalAIM will have to be watched fastidiously.
Accountability has now shifted from county well being departments to well being care plans, which don’t at all times meet high quality benchmarks. And well being plans within the 33 counties that didn't have pilots are ranging from scratch.
“There are severe considerations about Medi-Cal (well being care) plans on the bottom having the ability to implement a few of the work essential for CalAIM to actually be efficient and stay as much as its potential,” well being coverage knowledgeable Douglas stated.
“In some instances, plans wrestle to ship high quality care throughout what we consider as very primary measures: childhood immunizations, are individuals getting mammograms on time, simply very primary preventive care and continual illness administration.”
Accountability is particularly vital for bettering fairness amongst minorities, advocates say.
“Communities of colour are disproportionately impacted by these identical components: lack of housing, lack of revenue, lack of meals safety,” stated Cary Sanders, senior coverage director for the California Pan-Ethnic Well being Community.
Well being plans want to offer providers which can be “linguistically and culturally applicable,” Sanders stated.
One vital piece of the pilot applications that was neglected of CalAIM is authorized support. In counties that funded authorized support through the pilot applications, legal professionals and paralegals had been stationed in medical clinics to help sufferers who wanted assist with profit denials, eviction notices, immigration points, or home abuse instances.
Ceaselessly sufferers and even their docs don’t notice that their situation might use the assistance of a lawyer, stated Daniel Nesbit, managing lawyer for medical-legal partnerships with California Rural Authorized Help. Nesbit stated through the pilot program in Monterey County his crew helped 700 purchasers with greater than 1,000 instances.
“A very good instance is somebody fighting some form of medical situation, and it’s making it onerous for them to go to work day by day and do their job to the total extent,” Nesbit stated. “They may not know, for instance, that they've a attainable proper to an inexpensive lodging beneath the Individuals with Disabilities Act.”
Alameda and Contra Costa counties, which contracted with Bay Space Authorized Support to take part within the pilot, employed 5 further attorneys devoted to helping Medi-Cal sufferers. The partnership helped attain individuals who ordinarily wouldn’t be capable to entry authorized support as a result of their incapacity prevented them from attending an appointment or they didn’t have a telephone quantity or tackle. Case managers had been capable of hyperlink individuals to the attorneys, accounting for 300 referrals a 12 months.
However when the pilot led to December and state funding dried up, attorneys had been reassigned and are not capable of concentrate on Medi-Cal sufferers.
“I’m nonetheless getting emails and telephone calls from the case managers I labored with who I feel are actually type of scrambling to determine learn how to assist,” stated Abby Khodayari, an lawyer who labored in Contra Costa County’s program. “Case managers are hoping to get assist analyzing eviction notices and determining the validity of them. It’s onerous not having devoted time to have the ability to spend engaged on these points.”
Whereas authorized providers aren’t explicitly named as considered one of 14 pre-approved providers beneath CalAIM, the Division of Well being Care Companies stated well being plans might combine them as a part of supportive housing providers, that are lined.
However attorneys say it’s unlikely to occur except plans get particular ensures that CalAIM will cowl the fee. They hope that subsequent phases of CalAIM will embody authorized support.
“There hasn’t been a well being plan right here in LA who’s come ahead and stated we wish to provide these authorized providers,” stated Gerson Sorto, a managing lawyer with Neighborhood Authorized Companies of Los Angeles.
Los Angeles County has continued funding their partnership by way of the summer time, however there’s no everlasting cash in sight. “As of at the moment, there is no such thing as a funding secured or confirmed past June 30,” Sorto stated.
Life beneath ‘entire individual care’
Again on the Radisson Lodge in Oakland, the shelter the place El is ready patiently to maneuver into his new residence, he watches a house renovation present on the tv. He likes to see how the hosts redesign the inside and will get concepts for his personal future house.
Earlier than dropping his job, El lived in an residence close to Lake Merritt however hasn’t had a spot to name his personal in years. After he enrolled in Alameda County’s pilot program, issues began turning round for him.
“These individuals actually respect you and assist when you ask for it,” El stated.
A part of this system is connecting Medi-Cal sufferers to friends with comparable backgrounds.
“You'll be able to’t inform them ‘do that and do this.’ You stroll alongside somebody and help no matter they’ve bought occurring,” stated Michael Webb, a CalAIM peer help navigator who struggled with habit and homelessness. “Most significantly,” he stated, “somebody to hear. I won't have any reply in any respect however there’s energy in listening.”
Down the corridor from El’s room, shelter displays are delivering lunch to residents that may’t make it to the eating room. Lunch is a rooster sandwich, banana, salad and a soda, however these with dietary restrictions or sure medical circumstances like diabetes get tailor-made meals.
As a part of the CalAIM program, caretakers carry out wellness checks on shelter residents with disabilities, serving to them clear, bathe and use the restroom.
Within the foyer, an consumption employee asks a brand new visitor about his seizure dysfunction and works to hyperlink him to his CalAIM crew of well being care suppliers, case employees and housing navigators. As this system grows, tens of millions extra Californians might profit. On today alone, the Oakland crew expects to enroll eight new individuals.