September 4, 2024

Submitted via email to PHMSection@dhcs.ca.gov

Dear Director Baass,

On behalf of Connecting for Better Health, thank you for the opportunity to provide comment on the Draft Closed-Loop Referral Implementation Guidance. We are pleased to see DHCS take this step to increase the number of Medi-Cal members successfully connected to the services they need, and encourage DHCS to ensure this policy guidance truly represents a closed loop.

Connecting for Better Health (C4BH) is a diverse coalition of providers, patient advocates, caregivers, health plans, technology innovators, and community-based organizations dedicated to advancing health and social data sharing to improve the health of all Californians. Our vision is that every Californian and their care team will have the information and insights they need to make care seamless, high-quality, and affordable.

In order to ensure that Closed-Loop Referrals (CLRs) for Enhanced Care Management (ECM) and Community Supports are member-centered, Medi-Cal members should be able to rely on their existing relationship with referring providers. As the guidance is currently written, we are concerned that the process described is not truly a closed loop. As keeping trusted entities “in the loop” is essential to whole-person care, we encourage DHCS to consider requiring notification of the referring entity when a referral is accepted or denied, and of a member’s receipt of service.

Additionally, C4BH respectfully submits the following recommendations for consideration:

• Closed-Loop Referral processes should support CalAIM providers. CLR implementation should reduce the burden on CalAIM providers, particularly in multiple-Managed Care Plan (MCP) counties. We thank DHCS for the inclusion of language that MCPs cannot require additional data elements from ECM and Community Supports providers. While we also appreciate the inclusion of language that MCPs operating in the same county should make “reasonable efforts to align and simplify referral pathways,” there remain concerns that providers in multiple-MCP counties may have to juggle different referral platforms and processes. We recommend that DHCS include a recommendation that MCPs in the same county produce a shared plan of how ECM and Community Supports providers will fulfill closed-loop referral requirements with multiple MCPs.
• Closed-Loop Referral processes should be member-centered. In addition to notifying the referring provider about the closure of the referral loop, active consultation of the member is critical for the success of referrals to ECM and Community Supports. The Vision for CLR Roles and Responsibilities Use Case matrix (page 19) should include Consulting the member, not just Informing the member. Otherwise, providers spend time and resources making referrals for a member who is not engaged in the process, and may ultimately decline the service. This is neither trauma-informed nor cost-effective. We recommend that member consultation be required at the point of the referral, with special consideration for children and other vulnerable populations who may have designated caregivers or guardians authorized to receive the member’s information.
• Alignment with the California Data Exchange Framework (DxF) and CalAIM Data Sharing Authorization Guidance (DSAG) is critical. We thank DHCS for including mention of both the DxF and CalAIM DSAG in the draft guidance. When possible, we encourage DHCS to reinforce the importance of consent management, and remind MCPs and providers if and where consent is required. As part of DxF implementation, entities across California are working with local partners on establishing referral pathways using Qualified Health Information Organizations (QHIOs) and other data sharing intermediaries. We encourage DHCS to collect instances of CalAIM referrals working well across the state, and ensure the CLR implementation guidance does not disrupt existing processes or workflows.
  • Additionally, while we understand the need to implement this policy with a narrow focus on ECM and Community Supports on January 1, 2025, it could lead to a more fractured system if MCPs are not encouraged to connect CLR processes to other Medi-Cal benefits and state initiatives that include social service referrals. We recommend that the policy include reference to how this policy should align with Medi-Cal broadly, else we risk further siloing our delivery system.
• Managed Care Plans should work with the CalAIM stakeholders in their communities to ensure involvement and collaboration on data-driven decision-making. We appreciate the inclusion of the requirement that MCPs utilize referral information to take “systemic, data-driven actions” (page 12). CLRs can offer valuable insights into how CalAIM services are working in communities and where there are gaps to be addressed. We recommend including guidance on how MCPs should publicly report out and utilize this data to improve care delivery with their local CalAIM partners.
  • Stakeholders expressed some concern that the proposed documentation options for the “Reason for Referral Loop Closure” data element (page 9) are unclear and may present gaps in referral tracking and follow up. To support the collection of complete information on known closures, we recommend that DHCS should provide clear definitions for these documentation options and consider the removal of the “unknown” option.

We thank you for the opportunity to provide feedback on the Draft Closed Loop Referral Implementation Guidance, and look forward to our continued collaboration on advancing data sharing across California. If you have any questions, please don’t hesitate to reach out to discuss further.

Sincerely,
Connecting for Better Health