This pragmatic, cluster-randomized trial will evaluate whether a comprehensive CalAIM-aligned care model consisting of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential care coordination improves population health outcomes among high-risk Medi-Cal managed care members in California compared with usual CalAIM service delivery. The intervention is intended to improve continuity of care after discharge, reduce potentially avoidable utilization, increase successful linkage to outpatient and social supports, and improve community tenure and patient-reported outcomes.
Adult Medi-Cal managed care member in California.
Identified as high-risk for poor outcomes based on plan stratification or qualifying CalAIM criteria.
Eligible for ECM and at least one of the following: Transitional Care Services, Community Supports related to post-acute recovery, housing/residential stabilization, or nursing facility transition/diversion.
Recent discharge or active transition from hospital, emergency department, skilled nursing facility, post-acute facility, recuperative care, assisted living, residential behavioral health setting, or other qualifying level-of-care transition.
Enrollment in hospice or expected survival less than 6 months at the time of the index episode.
Long-term custodial institutional placement without an anticipated community transition plan.
Current incarceration or detention is preventing intervention delivery.
Previous enrollment in this study during the same observation window.
Parallel
Comprehensive CalAIM Care Bundle
BehavioralA standardized service bundle composed of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential care coordination designed to improve continuity, utilization, and community tenure.
Usual CalAIM Service Delivery
Other interventionStandard local delivery of CalAIM-related services without the added structured bundle, monitoring cadence, and transition optimization workflow used in the intervention arm.
30-day all-cause acute inpatient readmission rate
Proportion of enrolled participants experiencing an unplanned all-cause inpatient readmission within 30 days after index discharge or index transition episode.
Emergency department utilization
Number of ED visits per participant
Successful ambulatory follow-up
Proportion with completed primary care or appropriate ambulatory follow-up within 7 days for high-risk transition episodes and within 30 days overall
Medication reconciliation completion
Proportion with documented medication reconciliation after discharge
Community tenure
Days alive and residing in community-based or home-like settings without return to institutional care
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