CalAIM Population of Focus
Adult High Utilizers. The fifth ED visit this year is not an emergency — it's a system failure.
About this POF
This is DHCS APL 21-012 Adult ECM Population of Focus #2 — Adult High Utilizers. Atlas targets adults whose utilization pattern signals unmet primary care, behavioral health, or social needs. Multidisciplinary teams engage in the hospital, follow the member home, and stay through the first 30, 60, and 90 days when readmission risk is highest.
Who qualifies
- Five or more emergency department visits in a rolling six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence, AND/OR
- Three or more unplanned hospital and/or short-term skilled nursing facility stays in a rolling six-month period that could have been avoided
- MCPs may also authorize ECM for other individuals with a pattern of very high utilization that could have been avoided
- Co-occurring behavioral health, SUD, or unmet social needs driving avoidable utilization
- Recently discharged from an inpatient stay with medication, follow-up, or housing gaps
What we do
The full CalAIM toolkit — pointed at one population.
- 01
In-hospital engagement & discharge planning
Care managers meet members bedside, reconcile medications, book the 7-day follow-up before discharge, and arrange transportation home.
- 02
Transitional care (30 / 60 / 90 days)
Home visits, telephonic check-ins, and rapid access to a clinician — the intensive touch window that drives down 30-day readmission rates.
- 03
Chronic disease management
RN-led care planning for CHF, COPD, diabetes, and ESRD — including remote monitoring, medication titration support, and coordination with specialty care.
- 04
Behavioral health & SUD integration
Warm handoff to co-located behavioral health and coordination with county specialty mental health when medical necessity is met.
- 05
Social needs & Community Supports
Housing, food, transportation, and medically-tailored meals — the CalAIM Community Supports that address the drivers of avoidable utilization.
The stakes
Why concentrating care here matters.
- 5%
- Of Medi-Cal members drive ~50% of total spending
- 1 in 5
- Medicare/Medicaid patients readmitted within 30 days of discharge
- 7 days
- Target for post-discharge PCP follow-up to prevent readmission
Source · DHCS CalAIM population health analysis
Source · CMS / AHRQ Hospital Readmissions data
Source · NCQA HEDIS transitions-of-care measure
Refer a member
Hospital case managers, ED social workers, health plan utilization teams, PCPs, and specialty clinics can refer members meeting utilization criteria. We also accept self- and family referrals.
For members & families
Enroll yourself or a loved one — we'll walk you through every step, in your language, at your pace.
Other populations of focus
Individuals Transitioning from Incarceration
Warm-handoff care for adults and youth returning to the community from jail, prison, or juvenile facilities.
Youth Transitioning from Incarceration
Developmentally-tailored care for transitional-age youth involved in the juvenile justice system.
Individuals and Families Experiencing Homelessness
Street-based, harm-reduction care for individuals and families experiencing — or imminently facing — homelessness, with complex physical, behavioral, or developmental health needs.
Birth Equity (Pregnant & Postpartum SMI/SUD)
Culturally-matched care for pregnant and postpartum members at elevated risk of maternal morbidity — delivered under the Adult SMI/SUD Population of Focus.