Revolutionizing Behavioral Health: California’s CalAIM Initiative and Beyond

Behavioral health is intricately linked to an individual’s physical health, social stability, and economic well-being. Yet in the United States, access to and investments in behavioral health, particularly within the health safety net, lags far behind physical healthcare. Untreated mental health issues such as substance use or other psychological disorders are prevalent among those experiencing homelessness. Moreover, individuals with behavioral health conditions face an elevated risk of chronic diseases like heart disease and diabetes, along with unstable employment, housing insecurity, and incarceration.

Historically, limited Medicaid funding, as well as the absence of integrated behavioral healthcare within other healthcare settings, has exacerbated these issues. This underscores the urgent need for more integrated care and improved service delivery to address this critical public health concern. 

While many states are actively working toward change, the journey is a complex one. Nevertheless, numerous steps can be taken at the county and state levels to initiate and advance these programs forward.

California as a model

California Advancing and Innovating Medi-Cal (CalAIM) is an ambitious statewide initiative to redesign California’s Medicaid program to address the needs of Medi-Cal members through a holistic, whole-person approach. As part of the initiative, the Department of Health Care Services (DHCS) is making once-in-a-lifetime investments to improve quality of care and service delivery in the state’s behavioral health system. Data sharing, which is key to this effort in California, is relevant to states around the country that are embarking on equally ambitious Medicaid 1115 Waiver programs.

In a case study recently published by the California Health Care Foundation, we highlight our experience collaborating with Santa Cruz County Behavioral Health Services (BHS), a trailblazer in utilizing health information exchange (HIE) to enhance care delivery for behavioral health clients. The County’s participation in the Behavioral Health Quality Improvement Program (BHQIP) has augmented its efforts to foster data-driven care across all its departments and health system partners. 

The insights gained from this experience offer valuable lessons for behavioral health agencies, community-based organizations, healthcare institutions, and Medicaid programs nationwide.

The California effort rests on three essential requirements:

  1. Payment reform: Adopting new Current Procedural Terminology (CPT)/related service codes and to improve billing and claiming workflows for services
  2. Adopting policy changes: Implementing standardized screening tools and other policies that streamline service delivery 
  3. Building capacity for data exchange: Direct connections to managed care plans/HIE, embracing data mapping, and driving quality improvements and care-coordination efforts

On the ground in Santa Cruz County

To kick-start BHQIP, Santa Cruz County assembled a team of subject matter experts across these three core areas. The Intrepid and BHS teams have overseen the completion of each required milestone, including stakeholders from billing and quality improvement, leaders from Drug Medi-Cal Organized Delivery System and managed care plans providing non-specialty mental health services, and representatives from the region’s HIE, Serving Communities Health Information Organization (SCHIO), as well as heavy users of Netsmart’s myAvatar, the county Health Services Agency’s behavioral health electronic health record played pivotal roles. 

With these teams in place, leaders could better envision how BHQIP’s goals contribute to the larger data exchange ecosystem and begin to develop action plans for the individual milestones. 

Throughout Santa Cruz County’s journey, there were numerous challenges and successes worth sharing to guide future reform efforts across the United States.

Ongoing workforce shortages

CalAIM and similar programs will take years to implement, with many moving parts and lengthy timelines. This can be challenging, especially when resources are scarce. 

In the case study, Subé Robertson, Director of Quality Improvement at Santa Cruz County BHS explained, “Everyone’s plates are overflowing, which makes it tough to feel as if these initiatives are sustainable. We’re expected to make change upon change in a really short timeframe without the staff we need to make [those changes] happen, which doesn’t feel great when we come into work every day bringing our best.” 

Additionally, existing initiatives and agency workloads remained the same. On top of implementing BHQIP, counties were still expected to keep up with existing agency priorities.

As workforce shortages persist, proactive and realistic approaches to reaching set goals and maintaining existing projects and workloads will be essential to keep everything moving forward.

Data-driven projects and strategic vision

Widespread staffing shortages mean that Santa Cruz County has been working with approximately 30% of its positions unfilled, leading to major gaps in the necessary skill sets and organizational capacity to continue making headway on CalAIM goals. One way counties can succeed in this environment is to secure an experienced data strategist who can take a bird’s-eye view of the problems at hand. 

To that point, Tiffany Cantrell-Warren, Santa Cruz County BHS Director, says in the case study, “We need someone who can understand what we have, envision how they should all work together, and direct the necessary changes so that we’re meeting our objectives efficiently.”

Complicated regulatory landscape

Making sense of privacy rules governing the exchange of behavioral health data is challenging, especially when state and federal regulations are both in play. This is particularly important in the context of BHQIP. As the program’s objectives depend on robust data exchange, privacy regulations such as 42 CFR Part 2 — which severely restricts the exchange of substance use disorder data — pose a major obstacle to achieving stated goals. While major policy changes are out of a county’s control, leaders can urge state-level officials to provide more guidance and meaningful resources to help clarify local and national laws. 

Becky Shoemaker, Senior Project Manager at SCHIO, addresses this in the case study. “We need to change the regulations and change how things are being done if we are truly going to achieve whole-person care,” she says. “The state could do a better job of relaying information and putting mandates in place that would allow participants to feel comfortable with sharing information appropriately.” 

Value of a neutral convener 

SCHIO has helped transform Santa Cruz County’s data transformation efforts by serving as a neutral party when county and state stakeholders come together to make decisions about workflows and business agreements. Often, these conversations include access to data. 

“Everyone has their own interests to fight for. Whether we like it or not, access to data often becomes collateral in those conversations,” says Cantrell-Warren in the case study. “If you have an HIE that isn’t led by the county, and its driving mission is to facilitate data exchange to everyone equally, it offers the opportunity to have an objective opinion and a mediator when necessary.”

Health equity efforts at the forefront

Counties are useful administrative units in a state as large as California. But many Medi-Cal clients move within the state and may seek care in other counties. Leaders need to work with their neighboring counties to understand how to share data appropriately across county lines and how to coordinate care in larger health system transformation goals. 

“We don’t want to reinforce inequities that we saw during the pandemic, and we certainly don’t want to create new ones,” says Dan Chavez, SCHIO Executive Director, in the case study. “Taking a close look at improving care for a focused population like Medi-Cal [substance use disorder] and behavioral health clients is important, but we have to remember to roll up those learnings to other communities at risk so we can improve care and outcomes for everyone.”

The connection between mental health and overall well-being is undeniable, and the state of behavioral health in our country requires action. Initiatives like CalAIM in California and the work being done in Santa Cruz County offer valuable insights into the process of creating an integrated and equitable system. 

A few things to keep in mind before starting down your own path:

  • Seek out subject matter experts with the experience and knowledge to guide your organization through the complex reforms being introduced by DHCS.
  • Stay abreast of behavioral health policy developments at the state and federal levels.
  • Identify best practices and success stories from other stakeholders and assess whether they are feasible for, or applicable to, your organization.
  • California and other states are making historic investments in improving their behavioral health systems. Leverage these opportunities by staying connected to stakeholder groups and seeking out funding opportunities that can support similar reforms in your organization.

While challenges are an inevitable part of any big initiative to spur change, these experiences, lessons, and strategies shared above can guide efforts to reform behavioral health services across the nation.

Samuel Taylor is a senior consultant in the Policy Innovation Group at Intrepid Ascent. A self-described policy wonk, he has nearly a decade of experience in policy research and consulting. Samuel serves as the behavioral health policy subject matter expert at Intrepid Ascent and leads implementation of several Behavioral Health Quality Improvement Program engagements with California behavioral health agencies. He holds a Master of Social Work with a concentration in policy and research from Washington University in St. Louis.