California Integrated Care Management (CICM) Program

The goals of CICM are to:

• Promote integrated coordination across medical, behavioral health and social supports.
• Support member engagement in care and self-management.
• Reduce preventable emergency department (ED) visits and hospitalizations.
• Improve communication and shared care planning among providers.
• Address social determinants of health.
• Ensure continuity and safety during transitions of care.

For members experiencing homelessness or significant housing instability, care managers may meet members in a variety of community-based settings. A face-to-face (F2F) encounter may occur in person at:

• A member’s temporary or permanent residence.
• A shelter, navigation center, supportive housing site or motel placement.
• A clinic, community health center or behavioral health provider’s office.
• Locations where outreach services are provided.
• Public spaces where the member is safely reachable.

Telehealth or telephonic contact may be used when in-person contact is clinically inappropriate, not feasible or when member preference indicates. Documentation should reflect the reason for alternative contact and member engagement status.

Eligibility is determined based on CalAIM’s populations of focus criteria. Members may be evaluated for CICM at any time. Some members may be automatically enrolled and notified of their enrollment. However, participation is voluntary and members may choose to discontinue care management support at any time without impact to their coverage or benefits.

Eligible members include those experiencing:

• Multiple or advanced chronic medical conditions.
• Co-occurring behavioral health needs impacting daily functioning.
• Frequent emergency department utilization or recent inpatient admissions.
• Housing instability or homelessness.
• Gaps in coordination across treating providers or service systems.
• Difficulty accessing or engaging in ongoing medical or behavioral health care.

Providers who participate in CICM are expected to:

• Communicate changes in a member’s health or care needs.
• Participate in ICP development and ICT meetings as requested.
• Encourage member participation in recommended care and services.
• Provide relevant clinical documentation to support coordinated care.
• Notify TotalCare Care Management of ED visits or hospital admissions when known.