Module 1: Cov Haujlwm ntawm Lub Hub
Tshooj 1: Txheej Txheem Cej Luam
Module 1 piav qhia txog piv txwv ntawm Hub cov haujlwm thiab qhia txog Hubs uas twb muaj lawm hauv California los qhia txog seb Hubs tuaj yeem pab txhawb kev sib txuas ntawm Medi-Cal Managed Care Plans (MCPs) thiab Cov Kws Muab Kev Pabcuam li cas.
Tom qab tshuaj xyuas Module 1, Medi-Cal MCPs thiab Hubs yuav nkag siab zoo dua txog:
- Cov koom haum uas yuav ua haujlwm ua Hub.
- Piv txwv cov haujlwm uas Hubs muab.
- Piv txwv ntawm Cov Chaw Pabcuam uas tam sim no ua haujlwm hauv California.
Cov Ntsiab Lus Tseem Ceeb ntawm Module 1
- Cov Chaw Pabcuam yog cov chaw uas tswj hwm cov haujlwm rau Medi-Cal Cov Neeg Muab Kev Pabcuam uas hais txog Kev Xav Tau Kev Noj Qab Haus Huv (HRSNs)
- Ntau hom koom haum yuav ua haujlwm ua Hub.
- Cov dej num uas Hubs muab sib txawv ntawm lub koom haum thiab thaum kawg txiav txim siab los ntawm kev sib tham ntawm MCPs, cov neeg muab kev pabcuam, thiab Hub.
Lus Cim: Cov Hubs ua haujlwm hauv cov qauv kev cog lus Medi-Cal Managed Care uas twb muaj lawm thiab DHCS tsis lees paub cov koom haum Hub. Saib Module 2 kom paub ntxiv.
Tshooj 2: Cov Koom Haum thiab Cov Haujlwm ntawm Lub Chaw Piv Txwv
Cov Koom Haum Piv Txwv Hub
Cov chaw ua haujlwm uas ua haujlwm tau zoo li Hub suav nrog, tab sis tsis txwv rau:
- Cov Koom Haum Hauv Zej Zog (CBOs)
- Cov chaw haujlwm kev noj qab haus huv hauv nroog
- Administrative Services Organizations (ASOs)/Third Party Administrators (TPAs)/Management Services Organizations (MSOs)
- Cov Koom Haum Kws Kho Mob Ywj Pheej (IPAs)
- Cov Pab Pawg Kho Mob
- Cov koom haum ntawm Chaw Kho Mob Tau Txais Kev Pom Zoo Los Ntawm Tsoom Fwv Teb Chaws (FQHC)
- Cov koom haum tsis muaj txiaj ntsig
- Cov koom haum ua lag luam
Piv txwv Hub Functions
Cov haujlwm uas Hubs muab sib txawv ntawm lub koom haum thiab thaum kawg txiav txim siab los ntawm kev sib tham ntawm MCPs, Cov Chaw Muab Kev Pabcuam, thiab Hub. Txawm hais tias ntau lub Hubs tuav cov ntawv cog lus ncaj qha nrog MCPs, lwm tus muab cov kev pabcuam hauv nruab nrab rau cov koom haum tom qab kev xa khoom. Qee lub Hubs kuj muab cov kev pabcuam ncaj qha rau cov Tswv Cuab Medi-Cal ntxiv rau lawv cov haujlwm kev tswj hwm.
Rooj 1 hauv qab no piav qhia txog cov piv txwv ntawm cov haujlwm uas Hubs muab. Dhau ntawm cov haujlwm no, ntau lub Hubs muab cov kev pabcuam ntxiv, suav nrog tab sis tsis txwv rau, kev ua haujlwm siab heev, cov peev xwm kev txawj xws li cov ntaub ntawv kho mob hluav taws xob sib xyaw (EHRs), kev koom tes ntawm cov tswv cuab, thiab kev muab cov kev pabcuam ncaj qha rau cov tswv cuab Medi-Cal.
Kev Cog Lus Ua Haujlwm Hauv Nruab Nrab thiab Kev Tswj Xyuas Network
Txhawb kev cog lus hauv nruab nrab thiab kev tswj hwm Network xws li:
- Tuav cov ntawv cog lus nrog ntau lub koom haum Muab Kev Pabcuam.
- Muab kev npaj txhij thiab kev txhawb nqa rau cov koom haum muab kev pabcuam.
- Koom nrog, nrhiav neeg ua haujlwm, thiab tswj hwm lub Network kom ntseeg tau tias cov kev pabcuam zoo uas tau muab rau cov Tswv Cuab thoob plaws hauv Network, suav nrog kev koom nrog cov Chaw Muab Kev Pabcuam los ntawm cov qauv kev tswj hwm koom tes.
- Tsim kom muaj peev xwm ntawm tus Muab Kev Pabcuam los ntawm kev muab kev cob qhia thiab kev pab txhawb nqa.
- Txhawb kev koom tes ntawm MCP, Cov Chaw Muab Kev Pabcuam, thiab CBOs los sib koom tes muab kev saib xyuas thiab txhawb kev ncaj ncees ntawm kev noj qab haus huv.
Kev Them Nyiaj Yooj Yim Rau Cov Neeg Muab Kev Pabcuam Medi-Cal Direct
Txhawb nqa cov txheej txheem them nqi thiab them nyiaj zoo rau cov Chaw Muab Kev Pabcuam uas tau cog lus, xws li:
- Txhawb cov Chaw Muab Kev Pabcuam uas tau cog lus kom xa cov ntawv thov hluav taws xob raws li txoj cai.
- Ua kom cov txheej txheem them nqi thiab them nyiaj ntawm Tus Muab Kev Pabcuam yooj yim dua.
Cov Ntaub Ntawv Tsim Kho
Txhawb nqa MCP cov ntaub ntawv sau thiab tshaj tawm cov haujlwm thiab cov kev cai, xws li:
- Muab cov software/platforms los txhawb kev tswj hwm kev xa mus thiab kev sau cov ntaub ntawv kev pabcuam.
- Ua kom cov haujlwm tswj cov ntaub ntawv nyob hauv nruab nrab los txhawb kev ua raws li cov ntaub ntawv, kev tshuaj xyuas, thiab kev tshaj tawm.
- Pab txhawb kev sib qhia cov ntaub ntawv ntawm cov koom haum koom tes los txhawb kev koom tes hla ntau qhov chaw.
Kev Ua Tau Zoo thiab Kev Tswj Xyuas Zoo
Txhawb nqa MCPs kom ua cov haujlwm saib xyuas kev ua tau zoo thiab kev txhim kho, xws li:
- Tsim kom muaj cov ntsuas kev ua tau zoo thiab kev ua tau zoo, ib lub tshuab rau kev saib xyuas kev ua tau zoo, thiab cov cuab yeej thiab cov txheej txheem kev ua kom ntseeg tau tias zoo.
- Muab kev txhawb nqa thiab kev cob qhia hauv kev kho mob uas tsim los txhim kho qhov zoo thiab kev saib xyuas.
- Pab txhawb kom muaj kev kawm los ntawm cov phooj ywg los txhawb kev koom tes thoob plaws hauv kev lag luam.
Tshooj 3: Qhov Chaw Qhia Txog Hub
Cov chaw ua haujlwm hauv California tam sim no muab ntau yam kev ua haujlwm thiab cov kev pabcuam ntxiv. Daim Duab 1 qhia txog cov koom haum ua haujlwm ua Lub Chaw Pabcuam uas muaj cov ntawv cog lus lossis Cov Ntawv Cog Lus Ua Lag Luam (BAAs) uas twb muaj lawm nrog ib lossis ntau tus MCPs thiab Cov Chaw Muab Kev Pabcuam los txhawb kev muab cov txiaj ntsig Medi-Cal. Yog xav paub ntxiv txog Hubs, suav nrog cov piv txwv ntawm Hubs uas tam sim no ua haujlwm hauv lub xeev, thov mus saib California Health Care Foundation (CHCF) phau ntawv Exploring Emerging Medi-Cal Community Care Hubs.
Daim Duab 1: Qhov Chaw Qhia Txog Hub
Los Angeles County leverages existing county infrastructure, including a care management system and referral management processes, to administer ECM and Community Supports services to eligible Medi-Cal Members within the county system. The county is contracted with all six county MCPs to administer Community Supports, and with two county MCPs to administer ECM. This program initially relied on braiding and blending funds from initiatives like Measure H and the Whole Person Care pilot and is sustained by new investments through the Incentive Payment Program and Providing Access and Transforming Health Capacity and Infrastructure Transition, Expansion, and Development Initiative in addition to ongoing braided funding that includes Measure H/A and CalAIM Community Supports.
Integrated Health Partners of Southern California (IHP) is a clinically integrated Network of Federally Qualified Health Centers providing ECM services in Riverside and San Diego counties. IHP contracts with three of the local MCPs and centralizes contracting, referrals, claims, billing, and training for FQHCs in their Network. As a risk-bearing organization, IHP is focused on improving quality measures and Member outcomes.
Aliados Health is a non-profit regional consortium that supports community health centers across six Northern California counties. Operating as an Administrative Services Entity since 2023, Aliados Health has a BAA with an MCP and contracts with 13 organizations, including health centers, local government and community-based social service Providers, that provide ECM and/or Community Supports services, to support onboarding, training, documentation, invoicing, reporting, quality oversight, audits, and advocacy. Aliados is developing similar support services for the Medi-Cal CHW benefit.