Acute Care Transitions (ACT) is Institute on Aging’s model for enrolling eligible patients into CalAIM Enhanced Care Management while they are still in the hospital, then carrying that relationship into the community through a warm handoff.
Built in partnership with San Francisco Health Plan and three San Francisco hospitals, ACT is now operating across 14 acute care settings.
Recovery does not happen in the hospital. It happens at home, and it depends on things a discharge plan cannot deliver on its own: stable housing, food, transportation, a working relationship with a primary care provider, and someone paying attention.
of Medicare discharges result in a 30-day readmission
in avoidable costs to the health system each year
Jencks SF, Williams MV, Coleman EA. New England Journal of Medicine. 2009;360(14):1418–1428. Corroborated by AHRQ HCUP Statistical Brief #304 (2023), which found the 30-day all-cause readmission rate held at 13.9 per 100 index stays from 2016 to 2020.
Four steps, from the hospital bed to a stable life in the community.
IOA care managers are embedded in emergency departments and inpatient units. They identify eligible patients and enroll them during the acute encounter, before anyone is lost to follow-up.
Discharge is a deliberate handoff to a named IOA care manager, not a referral into a queue. Engagement begins before discharge, so the relationship already exists when the patient goes home.
Rapid post-discharge contact, home and field visits, and a person-defined care plan built with the member. Housing and health-related social needs are addressed alongside clinical follow-up.
Aligned authorizations, health information exchange data, and EHR access keep the hospital, IOA, and the health plan working from the same picture of the member.
One-year pilot period, July 1, 2025 to June 30, 2026.
acute care settings
clients enrolled in ECM
retention after 30 days
of referred patients enroll
The need
Poorly coordinated hospital-to-community transitions drive avoidable utilization, poor experiences, and gaps in care for adults with complex needs.
The objective
Embed IOA CalAIM ECM care managers at the bedside and ensure warm handoffs into community-based care and housing supports.
The scope
Medi-Cal eligible adults 18 and older who are San Francisco Health Plan beneficiaries, enrolled during emergency department and inpatient encounters at three San Francisco hospitals.
ACT works because the payer, the provider, and the hospital each own a clearly defined piece of it.
Eligibility, reimbursement, authorizations, and data sharing. San Francisco Health Plan is IOA’s founding ACT payer partner.
Bedside enrollment, field care management, and evaluation lead. IOA is one of California’s largest CalAIM ECM providers.
Acute identification, discharge planning, and the warm handoff. Care managers and discharge planners are the front door to the model.
Acute Care Transitions (ACT) is a care transition model in which CalAIM Enhanced Care Management care managers are embedded in emergency departments and inpatient units. Eligible patients are identified and enrolled during the acute encounter, then handed off directly to a community-based care manager who follows them home. It was developed by Institute on Aging in partnership with San Francisco Health Plan.
Standard ECM outreach works from health plan lists, contacting members by phone, mail, and door knocks after the fact. Response rates are low and lists run dry. ACT reverses the sequence: it meets the member during the acute encounter, when the need is immediate and the person is present. In IOA’s pilot, 65% of referred patients enrolled and 89% were still engaged after 30 days.
Three things: give IOA care managers access to the units, build the handoff into your existing discharge planning workflow, and agree on how data moves between the hospital, IOA, and the health plan. IOA supplies the care managers, the training, and the community-side infrastructure.
Medi-Cal managed care members aged 18 and older who fall into a CalAIM population of focus, most commonly people experiencing homelessness or housing insecurity, people with serious behavioral health or substance use needs, and high utilizers of emergency departments and hospitals. Eligibility is confirmed with the member’s health plan.
Enhanced Care Management is a Medi-Cal benefit reimbursed through the member’s managed care plan. Hospitals are not billed for ECM enrollment or care management. Contact our partnerships team to discuss what an agreement looks like in your county.
Data sharing runs through agreements with the health plan and the hospital, using aligned authorizations, health information exchange data, and EHR access. Enrollment is voluntary and consented by the member.
Yes. The pilot launched in San Francisco, and Institute on Aging delivers CalAIM Enhanced Care Management across 15 California counties. We are actively expanding ACT with new hospital, health system, and county partners.
We are expanding ACT with hospitals, health systems, health plans, and counties across California. Tell us about your population and we will walk you through what a partnership looks like.
If you discharge patients, manage a Medi-Cal population, or run a county program, and you need a community partner who can take the handoff and keep it.
