2022 Impact Report
Leading Through Action for Healthier Communities

AltaMed Community Health Workers: Building Bridges to Care

Recent changes to the Medi-Cal program have created opportunities for AltaMed Community Health Workers (CHWs) to engage and provide expanded service to our patients. 

In 2022, the California Department of Health Care Services launched CalAIM (California Advancing and Innovating Medi-Cal), a multi-year initiative to transform Medi-Cal and provide members with more coordinated, person-centered, and equitable care. A key component of CalAIM is Enhanced Care Management (ECM), a new statewide benefit available to eligible members with complex health and social needs. ECM will now make it easier for Medi-Cal members to get the right care at the right time in the right setting, and receive comprehensive care that goes beyond the doctor’s office or hospital.

Our CHWs completed ECM training in August and soon after began outreach to the community. After only three months the team had successfully enrolled 80 patients. In December 2022, with the guidance and support of her CHW, one of our ECM-enrolled patients was able to meet her care plan goals, graduate, and move with her five-month-old from a shelter to an apartment.

Earlier in the year, the CHWs completed a three-month chronic disease management program to provide comprehensive care management to patients. For years, our CHWs—essential members of our Health Education and Wellness Department—have helped patients, most dealing with diabetes, achieve health goals by teaching them how to manage chronic diseases, adopt healthy behaviors, and navigate access to community services and other resources. Our CHWs have also provided psychosocial support, helping patients manage the social factors that prevent glucose control. Patients working with our CHWs experienced significant decreases in their blood sugar (A1C) levels.