California’s new Medi-Cal waiver — California Advancing and Innovating Medi-Cal — known as CalAIM, is a $6 billion, multi-year plan to transform California’s Medi-Cal program, which serves 1 in 3 Californians. Underpinning this plan is the Whole Person Care model, which seeks to coordinate a patient’s health, behavioral health and social services in a way that meets their unique needs and health goals. To achieve this, CalAIM includes a multi-year investment to build a standardized data collection and data sharing framework.
The unequal impacts of COVID-19 and the ongoing crisis of police violence in communities of color have exacerbated mistrust and disconnection between these communities and the health care system. This makes achieving patient-centered care a challenge. Studies show that brief messages and two-way communication via text builds people’s trust and engagement in health care and educational settings.
The Federal Communications Commission is reviewing a request by the Department of Health and Human Services to allow health plan administrators and providers to use text messaging to communicate with Medicaid members (Medi-Cal is the name California gives to its Medicaid program). The goal is to extend emergency regulations enacted during the pandemic and forestall a significant drop in Medicaid coverage when the federally declared Public Health Emergency ends. Not making this emergency rule permanent for all Medicaid outreach would be a missed opportunity for the CalAIM data strategy.
When I was a philanthropy executive at Sutter Health in 2014, we championed a series of novel partnerships addressing the needs of Medi-Cal patients at Alta Bates Summit Medical Center in Oakland. The center was selected to participate in the Camden Coalition of Healthcare Provider’s National Hotspotting Advisory Group and implemented an early version of an Emergency Department Frequent Utilizer program — a database of patients who repeatedly use emergency services. We became acutely aware of the information gaps we had about where high-utilizer patients go for care and why. These included small but important aspects of their lives, such as pet ownership. For example, one patient experiencing homelessness didn’t go to the shelter we repeatedly referred her to because it couldn’t accommodate her cat.
With the support of the California Health Care Foundation, Sutter Health and Alameda Health System we launched a first-of-its-kind Emergency Department data sharing initiative in Northern California. We adopted a data exchange platform created by the company Collective Medical, which we used to share emergency department data across six acute care hospitals in Oakland and surrounding areas.
Our experience with the information exchange platform taught us that electronic health records often don’t contain all the information needed to successfully help patients with complex health and social needs. Missing was an easily retrievable patient history listing their last visit to this and/or other hospitals, current medications, treatment plans, and social factors documented and available in one place. We needed to know the patients we were seeking to help. We needed them to trust us and stay connected with us for care to be delivered and for behavior change to take place.
Thanks to the data exchange, we managed to close some of the gaps between hospitals in the same community and electronic health records system. Yet, many of these patients do not have access to a regular mailing address, and they do not answer voice calls from unrecognized numbers which often leaves them outside of the bi-directional communication loop needed to support them.
Where does text messaging fit into the CalAIM technology stack? COVID-19 disrupted the traditional modes of care delivery and communication between patients and providers. Texting became a major tool used by providers — and other large public systems such as schools — to automate communications and follow-up tasks. Text messaging proved especially effective for equity-centered COVID-19 vaccine campaigns leveraging trusted relationships in the community to support engagement and outreach. Under California’s new Medi-Cal waiver, many of these community-based organizations now are serving as providers for health plans.
Let’s use the example of an older adult named William. Willam has asthma and is a frequent utilizer of our local emergency department. William is who the CalAIM waiver is designed to support, but the care system expects him to juggle multiple appointments or respond to an unknown caller to stay on track.
William has several informal relationships in his community that are his support system. William’s local church knows that he uses his first paycheck to cover rent and by the end of the month he’s barely able to put food in the fridge. Instead of playing phone tag, a check-in via text from the local food bank would make a big difference in his life.
Recently, there’s been a wave of both philanthropic and venture funding into community resource referral platforms like UniteUs, FindHelp and Alluma. Many of these platforms rely on phone calls, emails and, occasionally, text messaging for one-way outreach. Yet, the limits on the use of text messaging for Medicaid beneficiaries place our most vulnerable neighbors, and the community-based organizations they rely upon, on the wrong side of a new digital divide.
Let’s make text messaging part of our CalAIM toolkit for member engagement and outreach by health plans and their providers. With a $6 billion plan, we can afford to incorporate text messaging — a simple, low barrier-to-adoption tool — to shorten the steps it takes for a Medi-Cal beneficiary to make the best use of their health care plan.
Jim Hickman is the principal of Hickman Strategies, a strategy and innovation firm working with vulnerable populations.