Building Bridges: Five Lessons from Los Angeles on Driving Coordination in CalAIM’s Ecosystem of Care
December 18, 2024 | By Transform Health
Share This:
The brightly colored rooms at the Therapeutic Play Foundation (TPF) in Los Angeles spark hope and connection for all who walk through their doors for services addressing housing, behavioral health, maternal well-being, and more.
As a contracted CalAIM provider, TPF now receives Medicaid reimbursement in addition to grants to help fund its community-centered programming—a powerful illustration of CalAIM’s promise to integrate health and social care.
As the Department of Health Care Services (DHCS)-designated facilitator for Los Angeles County, Transform Health recently visited TPF to learn how they connect with so many Medi-Cal beneficiaries, particularly those who are hard to reach and have historically been underserved.
TPF’s executive director shared how her team employs a five-point outreach strategy to identify and engage community members—a method that has been pivotal to their success:
“Our communities are already navigating a lot, so you have to meet people where they are.”
– Nakeya Fields, Executive Director, Therapeutic Play Foundation
Five Lessons in Building an Ecosystem of Coordinated Care
Los Angeles, home to more than 25% of California’s entire Medi-Cal population, is piloting new programming for the nation’s largest Medicaid reform initiative.
Relationship-building is the key to systems transformation, especially between social service and health care partners who have never collaborated before. But how does a region as massive as Los Angeles achieve this?
Here are five proven strategies based on Transform Health’s work with stakeholders:
1. Meet Partners Where They Are
This wisdom extends beyond beneficiary engagement—it’s a guiding principle for stakeholder collaboration. At Transform Health, we’ve learned that effective engagement requires a mosaic of approaches. While we host monthly virtual collaborative sessions for CalAIM stakeholders, we also facilitate in-person office hours to meet providers in their own environments.
At a strategy session held in collaboration with the United American Indian Involvement, some attendees came with detailed spreadsheets of challenges; others shared verbal narratives. Each interaction reminded us that every partner’s learning and communication style is different, so our approach must adapt.
2. Engage Other Collaboratives
Collaboration is about aligning efforts—not reinventing the wheel. The Los Angeles Reentry Collaborative, for example, has been instrumental in supporting justice-involved populations. Rather than duplicating their efforts, we amplify their work by convening shared discussions and finding areas to align priorities. This practice of observing, uplifting, and integrating helps us build bridges across the ecosystem of care.
3. Invest in Tools that Drive Systems-Level Coordination
Care coordination in Los Angeles is intricately complex in a dynamic environment. The county’s sprawling geography, coupled with the complexities of its Medi-Cal population, often leaves providers isolated and needing connection to find answers.
To address this, we developed the Service Planning Area (SPA)-Level Directory, a critical new tool that aggregates provider data across managed care plans by SPA. This directory simplifies referrals, making it easier for providers to find and collaborate with their partners. It’s a small step toward untangling the maze of care and ensuring that no provider or patient falls through the cracks.
4. Deploy a Multi-Level Approach that Integrates a Policy Framework
Transform Health prioritizes serving as an effective translator to key decision-makers. We aggregate, synthesize, and elevate issues and proposed solutions to policymakers while supporting regional and organizational strategies in the interim because coordination challenges rarely exist in isolation.
Solutions often require action at the organizational, regional, and state levels. Take recuperative care, for instance. Discussions with the National Institute for Medical Respite Care (NIMRC) revealed that differences in requirements across state departments affected coordination. An individual provider cannot solve this alone.
5. Remain Transparent and Celebrate Wins
Partners deeply value transparency—knowing that even when solutions aren’t ready for deployment, their voices are heard and their needs are acknowledged. For example, while the state refines strategies to improve market awareness through feedback loops and public input, we ensure transparency by providing clear, monthly policy updates on these advancements.
At the same time, we highlight the continuous improvement strategies that providers are leading. In Los Angeles, organizations like Helpline Youth Counseling are taking proactive steps to bridge gaps by piloting in-service trainings with local partners. These efforts are helping build awareness and strengthen referral pipelines. By focusing on what is within their control and celebrating these incremental wins, providers are fostering collaboration and building the momentum needed to drive systems change—even as larger, long-term solutions take shape.
Reflection
Los Angeles is to California what California is to the nation: a bellwether for health reform. In 2024, through the relationships we’ve built, we’ve unveiled substantive solutions to drive the utilization of life-saving services and benefits—solutions that otherwise might have gone unnoticed. But at the foundation of this progress lies trust, built through the deliberate act of meeting partners where they are.
To join our efforts, please register on the DHCS website.
Transform Health is a nationally certified women and minority led health care consulting firm. Reach out to us today if you would like to work together. Contact Heather Bates, COO, and VP of Stakeholder Engagement at heather@transformhc.com. We would love to hear from you!