Institute on Aging is one of California’s largest providers of CalAIM Enhanced Care Management, operating across 15 counties with a multidisciplinary team of care managers.
The hard part of ECM is not the care plan. It is reaching the member in the first place, and keeping them engaged past week four. That is the problem we built the Acute Care Transitions model to solve.
Traditional ECM outreach works from plan-supplied eligibility lists: phone calls, letters, door hangers. Response rates are low, and the lists eventually run dry. Acute Care Transitions reverses the sequence by meeting the member during a hospital encounter, when the need is immediate and the person is present.
of referred patients enroll
retention after 30 days
completed a full episode of care
One of California’s largest CalAIM ECM providers, delivering across 15 counties from the Bay Area to the Central Coast, the Central Valley, and the Inland Empire.
Homelessness and housing insecurity, serious mental health and substance use needs, justice involvement, high acute utilization, institutional risk, and children and youth with complex medical needs.
Aligned authorizations, health information exchange data, and EHR integration keep eligibility, outreach, and services in sync across the plan, the hospital, and IOA.
ECM sits alongside more than 20 other IOA programs: home care, dementia care and caregiver coaching, adult day enrichment, mental health services, elder abuse prevention, and the 24/7 Friendship Line.
Our Acute Care Transitions program is evaluated with the RE-AIM framework across utilization, client and care team experience, and cost-effectiveness, with equity stratification built in.
Institute on Aging has served older adults and adults with disabilities in California since 1985. There is no shareholder interest competing with the member’s.
And more. Plan list current as of June 2026; participation varies by county.
Alameda, Merced, Monterey, Napa, Riverside, San Benito, San Bernardino, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Sutter, and Yolo.
If your members are concentrated somewhere we do not yet operate, that is worth a conversation. We have expanded the ACT model from a single-county pilot to a statewide program, and we are actively adding partners.
Three things. First, the Acute Care Transitions model, which finds members during hospital encounters rather than chasing them afterward. Second, more than 20 adjacent programs a care manager can pull from without a new referral relationship. Third, a formal evaluation program, so what we tell you is measured rather than asserted.
This is exactly what ACT was built for. Rather than relying only on list-based outreach, we position care managers where hard-to-reach members reliably turn up: emergency departments and inpatient units. In our pilot, 65% of referred patients enrolled and 88% stayed engaged past the first 30 days.
Yes. Our multidisciplinary teams serve all CalAIM populations of focus, including the harder ones: people experiencing homelessness, people with serious behavioral health and substance use needs, and adults transitioning out of institutions or incarceration.
California Integrated Care Management (CICM) carries the same benefit forward and adds dementia as a population of focus. Institute on Aging delivers under both names and has decades of dementia care experience, including our Companioa program, adult day enrichment, and caregiver coaching, which positions us well for that expansion.
DHCS-compliant documentation and reporting, plus closed-loop communication across the plan, the hospital, and IOA. Our ACT evaluation additionally tracks reach, engagement, utilization, and cost-effectiveness with equity stratification. Contact us to discuss the reporting cadence and format your team needs.
Our ECM care managers coordinate and refer members into Community Supports, including housing navigation and health-related social needs. Which Community Supports IOA delivers directly varies by county and contract. Contact our partnerships team for the current picture in your service area.
Tell us about your population and where engagement is breaking down, and we will tell you honestly whether we are the right partner.
Whether you want to send one referral today or build an embedded ACT program, start with a conversation.
