Enhanced Care Management for Population Health
(COMPASS-CalAIM Trial)
What You Need to Know Before You Apply
What is the purpose of this trial?
This trial tests a new approach to care for high-risk Medi-Cal members in California. It aims to determine if the Comprehensive CalAIM Care Bundle—which includes enhanced care management, community support, and post-hospital discharge assistance—improves health outcomes compared to usual services. The goal is to help individuals stay healthy in their communities, reduce unnecessary hospital visits, and connect them with essential support. The trial seeks Medi-Cal members recently discharged from a hospital or care facility who are considered high-risk for health issues. As an unphased trial, this study offers a unique opportunity to contribute to innovative care solutions that could benefit many in the community.
Will I have to stop taking my current medications?
The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.
What prior data suggests that this care model is safe for high-risk Medi-Cal members?
Research has shown that the Comprehensive CalAIM Care Bundle, which includes Enhanced Care Management and Community Supports, aims to improve health for individuals with complex medical needs. Data from the Department of Health Care Services indicates that these services are reaching more people and enhancing their health. Enhanced Care Management offers additional support beyond standard medical care, resulting in better health and social outcomes.
The available data reports no major side effects from these services, suggesting that the treatment is generally well-tolerated. This approach is already in use to some extent, which supports its safety. However, as this trial continues, more information about safety may emerge over time.12345Why are researchers excited about this trial?
Researchers are excited about the Enhanced Care Management for Population Health trial because it takes a comprehensive approach to healthcare that could significantly improve patient outcomes. Unlike standard CalAIM services, which involve routine care management and support, this trial bundles Enhanced Care Management with community supports, transitional care services, and residential care coordination. This integration aims to enhance continuity of care, optimize resource utilization, and extend community tenure for patients. By combining these elements, the trial seeks to provide a more holistic and effective model of care that could set a new standard in population health management.
What evidence suggests that this trial's treatments could be effective for improving population health outcomes?
Research has shown that Enhanced Care Management (ECM) and Community Supports positively impact individuals with complex medical and social needs. Recent data indicates that these services are expanding and assisting more people by providing more than traditional medical care. In this trial, participants in Arm A will receive the Comprehensive CalAIM Care Bundle, which includes ECM, Community Supports, and Transitional/Residential Care. This bundle aims to improve health by coordinating care for the whole person and addressing social needs. By ensuring continuous care and connecting individuals to community resources, this approach helps people remain healthier and more stable in their communities. Overall, early results suggest that these services can enhance health and well-being for those at high risk. Participants in Arm B will receive usual CalAIM services, which include routine services available through existing CalAIM operations.12346
Who Is on the Research Team?
Vernon R Pertelle
Principal Investigator
StratiHealth
Are You a Good Fit for This Trial?
This trial is for adults in California with Medi-Cal managed care who are considered high-risk for poor health outcomes. Participants must have recently left or be transitioning from a hospital, nursing facility, or similar setting and qualify for enhanced care management plus at least one support service like housing help or transitional care.Inclusion Criteria
Exclusion Criteria
Timeline for a Trial Participant
Screening
Participants are screened for eligibility to participate in the trial
Enhanced Care Management
Participants receive Enhanced Care Management, including community-based care management and transitional care services
Community Supports and Transitional Care
Participants receive community supports such as recuperative care and transitional care services to improve continuity and reduce readmissions
Follow-up
Participants are monitored for safety and effectiveness after the intervention, including assessment of readmissions and emergency department utilization
What Are the Treatments Tested in This Trial?
Interventions
- Comprehensive CalAIM Care Bundle
Trial Overview
The study compares usual CalAIM services to a more comprehensive package that includes enhanced care management, community supports, transitional care services, and residential coordination. Groups are assigned by location rather than individually.
How Is the Trial Designed?
2
Treatment groups
Experimental Treatment
Active Control
Participants in control clusters will receive routine services available through existing CalAIM operations, including any standard ECM, PHM, discharge planning, and Community Supports workflows already in place, without the enhanced bundled implementation protocol.
A 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.
Find a Clinic Near You
Who Is Running the Clinical Trial?
StratiHealth
Lead Sponsor
Citations
Medi-Cal Transformation Concept Paper
CalAIM initiatives such as Enhanced Care Management and Community Supports require effective data exchange between CalAIM providers, plans, and health care ...
Study Details | NCT07587073 | Comprehensive Enhanced ...
A standardized service bundle composed of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential ...
medi-cal reports strong growth in enhanced care management ...
DHCS today shared new data showing how Enhanced Care Management (ECM) and Community Supports are increasing and helping more people.
Enhanced Care Management and Community Supports
ECM is a new program that helps our Members with complex medical and social needs. These new services offer help beyond traditional medical services.
Enhanced Care Management and Community Supports - DHCS
Access to a single Lead Care Manager who provides comprehensive care management and coordinates their health and health-related care and services.
6.
healthnet.com
healthnet.com/content/dam/centene/healthnet/pdfs/provider/ca/provider-library/hn-medi-cal-ecm-provider-guide.pdfEnhanced Care Management Provider Reference Guide
1 Introduction. The Enhanced Care Management (ECM) benefit is a statewide benefit established by the. Department of Health Care Services (DHCS) to provide a ...
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