Your discharge planners and care managers already know which patients are going to come back. Institute on Aging enrolls those patients in CalAIM Enhanced Care Management while they are still in your building, then follows them into the community.
No cost to the hospital. Reimbursed as a Medi-Cal benefit through the member’s managed care plan.
Roughly 20% of Medicare discharges result in a 30-day readmission, at an estimated $17 billion or more in avoidable annual cost to the health system. For patients with complex social needs, a good discharge plan is not the bottleneck. What happens in the two weeks after discharge is.
A referral into a queue does not solve that. A named care manager who met the patient at the bedside does.
Jencks SF, Williams MV, Coleman EA. New England Journal of Medicine. 2009;360(14):1418–1428.
of referred patients enroll
retention after 30 days
clients enrolled across 14 acute care settings
1. Check the basics. The patient is 18 or older, has Medi-Cal managed care coverage, and fits a CalAIM population of focus. If you are not sure, call us and we will check.
2. Reach the care management team. Call 415.750.4111 during business hours. If an IOA care manager is already embedded in your facility, page them directly.
3. We take it from there. We confirm eligibility with the health plan, meet the patient at the bedside, and enroll before discharge.
Referrals move fast because acute care transitions have to. We do not put your patient in a queue.
No. Enhanced Care Management is a Medi-Cal benefit reimbursed through the member’s managed care plan. Hospitals are not billed for enrollment or ongoing care management.
In facilities where our care managers are already embedded, same day. Elsewhere, we work to reach the patient before discharge, which is the entire point of the model. Call 415.750.4111 as early in the stay as you can.
Enhanced Care Management is one of more than 20 Institute on Aging programs. If a patient does not qualify for ECM, we can often route them to home care, dementia care and caregiver coaching, mental health services, adult day enrichment, or the 24/7 Friendship Line. Tell us what the patient needs and we will find the right door.
Yes. ECM serves Medi-Cal members aged 18 and older. The average age of participants in our Acute Care Transitions program is 56.2 years, and nearly half are between 50 and 69. Children and youth with complex medical needs are also a CalAIM population of focus.
It sits inside it. Your discharge planner keeps ownership of the discharge; we become the community-side destination for the handoff, with a named person rather than an agency name. Where we have a formal ACT agreement, we build the handoff into your existing protocol rather than adding a parallel one.
Institute on Aging delivers CalAIM Enhanced Care Management across 15 California counties: Alameda, Merced, Monterey, Napa, Riverside, San Benito, San Bernardino, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Sutter, and Yolo. Plan partners include San Francisco Health Plan, Health Plan of San Mateo, Santa Clara Family Health Plan, Alameda Alliance for Health, Partnership HealthPlan of California, Inland Empire Health Plan, Central California Alliance for Health, and Molina Healthcare, among others. Plan participation varies by county.
Whether you want to send one referral today or build an embedded ACT program, start with a conversation.
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.
Whether you want to send one referral today or build an embedded ACT program, start with a conversation.
If you or someone you love has Medi-Cal, ongoing health or social needs, and could use one person keeping track of all of it.
