Full Circle’s STORY
Enabling Community Based Organizations to address health Equity Gaps
California’s Medi-Cal program is the nation’s largest and most diverse Medicaid program. While we have made significant gains in coverage, much work remains to improve quality and reduce disparities in health equity for the one in two children in California who rely on Medi-Cal to access health care.
There is broad agreement that strategies to improve health outcomes must go beyond the traditional medical model and address social drivers of health. Moreover, people prefer care providers who are similar to them delivering culturally sensitive interventions. Yet, the cultural, capability and data divide between the traditional health care and social service systems is vast. Smaller community-based organizations (CBOs) often are the best at engaging clients and earning trust, yet research shows most CalAIM-contracted providers are large organizations.
Full Circle Health Network aims to bridge these gaps. We were founded by and for CBOs and believe that CBOs are essential to achieving health equity goals and Medi-Cal’s CalAIM reforms because they are:
- Trusted messengers
- Embedded in community
- Diverse like their clients, and
- Culturally concordant
Through our collaborative partnership model and suite of administrative services, we increase linkages to supportive services for vulnerable children and families. We enable streamlined connection between community-based organizations and health plans. The result is better access to higher quality services that lead to meaningful improvements and the health and wellbeing for California’s most vulnerable residents.
Early Results
Full Circle Health Network has become the largest integrated network of community-based organizations in California delivering coordinated services to vulnerable children, youth and families. We have connected thousands of children to enhanced care management services and plan to connect thousands more.
We have Medi-Cal managed care plans that cover more than one in three Medi-Cal enrollees and a network of more than 120 providers with operations across two-thirds of the state. Full Circle has an exclusive, statewide arrangement with Kaiser Permanente Health Plan to be the network lead entity for CalAIM services available to children and families. To fund this work, Full Circle has received more than $10 million in start-up grants of which more than 60% went directly to providers to support their operations.
Full Circle was founded by leaders at the California Alliance of Child and Family Serving Agencies, which advocates for policies to support the state’s children, youth and families on behalf of its 160 member organizations.
What is Enhanced Care Management?
Enhanced Care Management (ECM) is intended to identify and close gaps in needed services, as well as ensure closed loop care coordination occurs between a child’s or family’s medical care, behavioral health care, and social services delivery systems. Because children and youth with complex needs are often already served by one or more case managers or other service providers within a fragmented delivery system, ECM offers coordination between systems. Instead of duplicating work already being done, ECM should facilitate effective communication and timely and necessary data sharing to make sure that the child or youth and their caregivers’ needs are being met with a whole person care approach. A key component of ECM is helping clients link to Community Supports offered by Medi-Cal managed care plans (MCPs) to address health-related social needs.
Specific Medi-Cal managed care enrollees with complex needs are eligible for ECM. This includes all children in family maintenance. Because supporting young children necessitates supporting their families, the ECM team can work with parents and caregivers under the child’s eligibility. Or the ECM team could have open cases for both the child(ren) and the parent(s).
Useful ECM links:
ECM Fact Sheet
ECM Child & Youth Spotlight
ECM Policy Guide (February 2024)
Community Supports for children & youth
What are Community Supports?
Community Supports are services intended to address Medi-Cal enrollees’ health-related social needs, help them live healthier lives, and avoid higher, costlier levels of care. Community Supports services have different eligibility criteria. MCP also have processes to determine if they are a “medically appropriate and cost-effective alternative” to other covered services.
Full Circle is focusing on the following Community Supports most likely to benefit children and youth:
» Asthma Remediation
» Housing Navigation
» Housing Tenancy and Sustaining Services
» Housing Deposits
» Caregiver Respite
Useful Community Supports links:
Community Supports Policy Guide (July 2023)
Community Supports Fact Sheet
Community Supports for children & youth
What are Community Health Workers?
CHW services are preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health and well-being. CHWs may include individuals known by a variety of job titles, including promotores, community health representatives, navigators, and other non-licensed public health workers, including violence prevention professionals.
A program cannot be paid to provide CHW and ECM services to the same client at the same time. Pursuing CHW service reimbursement is a way to diversify funding for existing services and reduce reliance on grants but current reimbursement rates are unlikely to cover the total cost.
Useful CHW links:
CHW Overview
Medi-Cal Provider Manual for the community health worker
Medi-Cal Provider Manual for asthma preventive services
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