CalAIM Program

Provide Services to All Populations of Focus:

• Adults:  

• Experiencing Homelessness 

• With at least 1 complex physical, behavioral, or developmental health need 

• High utilizer of Emergency Department or Hospitalization 

• Serious Mental Health 

• Substance Use Disorder 

• At risk of long-term care institutionalization 

• Need help transitioning from nursing facility to community 

• Transitioning from incarceration 

• Pregnant and postpartum 

• Children/Youth: 

• Homelessness 

• High utilizer of Emergency Department or Hospitalization 

• Serious Mental Health 

• Substance Use Disorder 

• Enrolled in California Children Services (CCS) or Whole Child Model 

• Involved in Child Welfare (Foster Care) 

• • Transitioning from Incarceration 

Services:

• Lead Case Managers meet assigned members where they are – on the street, in a shelter, at their doctor’s office, at their home, etc. 

• Provide service to members within 6 counties (Butte, Colusa, Glenn, Sutter, Tehama, and Yuba) 

• Coordinate health and health related care including physical, mental, dental, and social services. 

• Such as coordinating and help address concerns over appointments, transportation, connect to providers, making sure members could afford and get medications, health literacy, etc. 

• Health promotion – Health assessment, Care Plan, promote self-management and healthy lifestyle 

• Medical triage – RN Clinical Consultant provide medical triage to assess and address urgent and emergency needs 

• Transitional care 

• From nursing facilities, from incarceration, from hospital back to community 

• Individual and Family support services 

• Educate and assist with applying for benefits, such as IHSS, disability, CalFresh, assess members for other benefits. 

• Locate resources and incite in-kind donations to help address need 

• Connect members to Community Support services 

• Housing services 

• Food security and Healthy food – Medically tailor meal 

• Personal Care and Homemaker services 

• Other resources 

Team: 

• (14) Lead Case Managers providing Enhanced Care Management (ECM), coordinating both clinical and non-clinical care services. 

• (1) LVN Nursing Supervisor, oversees day-to-day operations of Lead Case Managers. 

• (1) RN Clinical Consultant, conduct medical triage and assessments. Reviews care plans to address the needs of each member. Improve the services provided and improve patient care. Provide trainings on care planning and case management. 

• (1) Enhanced Care Coordination Program Manager, oversees administration of program and activities. 

Please contact:

Bee Xiong
Enhanced Care Manager

(530) 674-4261  ext. 1251