California’s behavioral health system stands at a crossroads, shaped by decades of reform and a rapidly evolving technology landscape. As organizations strive to meet the demands of policies like CalAIM and pursue Certified Community Behavioral Health Clinic (CCBHC) models, they face unique challenges in integrating care, achieving compliance, and leveraging technology to support whole-person care.

In this three-part series, we’ll take a deep dive into the intersection of policy and technology in California’s behavioral health system:

• Today’s article provides a macro-level view of California’s policy landscape and its historical challenges with technology. We’ll examine how foundational reforms like the Short-Doyle Act, Title IX, and the Mental Health Services Act (MHSA) have shaped the current environment while highlighting ongoing complexities. Additionally, we’ll touch on the impact of new Medi-Cal reform initiatives, such as CalAIM, and what they mean for providers selecting the right technology solutions to support organizations.
• The second article will take a micro-level focus, delving into the specific challenges behavioral health organizations face within this landscape. From county-level variability to outdated systems, we’ll analyze how these hurdles impact providers and complicate care delivery.
• The third article will zero in on the unique challenges faced by large integrated care providers managing combined CMHC/CCBHCs and FQHCs under a single umbrella. We’ll explore the operational and technological complexities of coordinating care across these diverse models and discuss strategies for achieving success.

This series aims to equip stakeholders with actionable insights to navigate California’s behavioral health landscape and leverage technology for better outcomes. Let’s begin by examining the broader policy context and its historical roots.

Historical Context: The Evolution of Behavioral Health in California

California has a long history of behavioral health reform, shaped by landmark legislation and funding initiatives:

• Short-Doyle Act (1957): Shifted care from institutional settings to community-based programs, establishing a decentralized model.
• Title IX (1991): Transferred mental health responsibilities to counties, fostering localized control but creating variability in service delivery.
• Mental Health Services Act (2004): Introduced a 1% tax on high-income earners, generating $1.8 billion annually for mental health services.

While these reforms expanded access, they also introduced complexity. The Short-Doyle billing system relied on California-specific procedure codes rather than standardized CPT codes, complicating compliance. Each county developed unique reporting standards, requiring providers to meet local and state-level reporting mandates like CSI, CalOMS and MHSA.

CalAIM: A Pathway to Integration and Efficiency

The California Advancing and Innovating Medi-Cal (CalAIM) initiative officially launched on January 1, 2022. CalAIM is a multi-year effort by the California Department of Health Care Services (DHCS) aimed at transforming the Medi-Cal program to focus on whole-person care, health equity, and sustainability. It builds on the success of previous pilots like the Whole Person Care and Health Homes programs, with goals to improve health outcomes for Medi-Cal beneficiaries by addressing social determinants of health and providing more integrated and coordinated care.

For organizations pursuing the Certified Community Behavioral Health (CCBHC) model and/or integrated care, CalAIM offers a framework that can help align their efforts with state and federal requirements, promoting highly coordinated and integrated, whole-person care.

Key reforms include:

• Reimbursement Changes: Shifting from cost reimbursement to fee-for-service enables value-based payment models, aligning financial incentives with quality outcomes. California-specific Short-Doyle billing codes now align with CPT/HCPCS standards, simplifying billing and facilitating interoperability.
• “No Wrong Door” Policy: Ensures Medi-Cal beneficiaries can access care at any entry point, supporting seamless transitions between providers.
• Administrative Integration: Combines management of mental health and substance use disorder services into unified contracts, reducing redundancy.
• Documentation Redesign: Simplifies requirements, enabling clinicians to focus on care delivery rather than administrative tasks.
• Enhanced Care Management (ECM): A cornerstone of CalAIM, ECM provides intensive care coordination for Medi-Cal beneficiaries with complex health and social needs, addressing social determinants of health.
• Community Supports: Expands non-clinical services like housing support, food assistance, and respite care, allowing providers to address social determinants of health as part of Medi-Cal benefits.
• Standardized Statewide Managed Care Plan Policies: Establishes uniform managed care requirements to ensure consistency in care delivery across counties.
• Population Health Management: Implements a comprehensive population health approach, emphasizing prevention, early intervention, and chronic disease management.
• Integration of Physical and Behavioral Health Services: Enhances collaboration between physical and behavioral health providers, aiming for a more integrated approach to patient care.
• Peer Support Specialist Certification: Formalizes and expands the use of peer support specialists within the Medi-Cal system to enhance behavioral health services.

MCOs Partner with Counties with Three Models:

• County Organized Health Systems (COHS): The county operates a single MCO that processes all claims.
• Two-Plan Model: A public plan (often county-affiliated) and a commercial MCO operate side-by-side, and providers submit claims to the appropriate MCO.
• Geographic Managed Care (GMC): Multiple commercial MCOs contract directly with the state to manage care in specific regions.

Persistent Challenges in California’s Technology Landscape

Despite these reforms, technology gaps remain a significant barrier to integrated care and CCBHC readiness:

• Data Sharing and Interoperability: Fragmented systems and inconsistent data-sharing protocols hinder the seamless exchange of information between providers, counties, managed care organizations, and social services agencies. Some counties offer interoperability capabilities, such as Los Angeles with their Integrated Behavioral Health Information System (IBHIS) platform, but many still require duplicate data entry into their County EHR for provider organizations.  It has been challenging for providers to integrate with the counties that do offer integration. Compliance with the 21st Century Cures Act’s interoperability and information-blocking rules remains a challenge, as well as 42 CFR Part 2.
• Limited EHR Vendor Competition: The small number of EHR vendors focusing on behavioral health in California restricts options for providers, potentially stifling innovation. Developing systems that meet California’s complex regulatory requirements, such as CalAIM and Medi-Cal, and county-specific reporting requirements demands significant investment, deterring many vendors from entering the market. This results in fewer choices for providers seeking compliant and effective EHR solutions. Smaller organizations may struggle to afford high-cost systems designed for larger providers.
• Provider Burden: Complex reporting requirements for Medi-Cal and other funding sources lead to significant administrative burdens, often exacerbated by outdated or inefficient EHR functionalities and duplicate data entry for some counties.
• Workforce Training Gaps: Many behavioral health organizations lack the resources to train staff on new EHR functionalities or to optimize system use for care coordination and reporting.
• Rural and Underserved Areas: Providers in rural or underserved areas face unique challenges with connectivity and infrastructure, limiting the adoption of advanced EHR systems and telehealth tools.
• Scaling Community Supports in EHRs: Many EHRs lack the functionality to document and track Community Supports (e.g., housing, food assistance) offered under CalAIM, which are critical for addressing social determinants of health.
• Lack of Real-Time Data for Decision-Making: Delayed or incomplete data availability impairs providers’ ability to make timely, informed decisions for patient care. In cases where organizations are serving several counties without integration – requiring duplicate data entry – they often have incomplete data in their own EHR to manage their business.

Looking Ahead: Innovation Opportunities

• Collaborative Solutions: Partnerships between behavioral health providers, primary care organizations, and EHR vendors can drive innovation and create systems that better serve integrated care needs.
• Advocacy for Affordability: Engaging with policymakers and funding bodies to support smaller organizations in accessing advanced EHR systems can help level the playing field.
• Leveraging AI and Data Analytics: Emerging technologies can augment existing systems, filling gaps in reporting, compliance, and care coordination.

Key Challenges with EHRs in Supporting California Organizational Needs

Sector-Specific Design Limitations:

• Primary Care vs. Behavioral Health: Most EHRs excel in supporting one sector but fall short in delivering seamless integration for organizations providing whole-person care across both domains.
• Fragmented Functionality: Many systems lack features essential for integrated care, such as workflows that bridge physical and behavioral health services, or tools that enable multidisciplinary care teams to collaborate effectively.

Regulatory and Compliance Demands:

• California Medi-Cal Requirements: Complex reporting and compliance expectations, such as CalAIM initiatives like Enhanced Care Management (ECM) and Community Supports, require robust customization and adaptability.
• Federal Mandates: Organizations must also comply with 42 CFR Part 2 for substance use treatment confidentiality, as well as HRSA UDS reporting requirements for FQHCs. Balancing these federal and state regulations often necessitates manual workarounds or expensive system customizations.

Cost and Scalability Barriers:

• Smaller Organizations: High-cost EHRs designed for larger providers are often out of reach for smaller nonprofits, limiting their ability to invest in technology that aligns with their mission and operational needs.
• Data Integration Challenges with Interoperability: Few systems are equipped to manage seamless data exchange between primary care and behavioral health modules, hindering real-time care coordination and comprehensive reporting. Integrating EHRs with counties continues to be a challenge for contract providers.

Key Considerations in Selecting a Technology Partner

• Vendor Strength and Stability: Beyond evaluating the technology itself, organizations must assess the vendor’s stability, market reputation, and commitment to long-term partnership. A strong vendor should be equipped to adapt to evolving federal and state regulations while offering ongoing support. It is important for vendors to have a strong presence in a state in the behavioral health market, so an organization isn’t a single voice to advocate for enhancements with national enteprise commercial vendors.

Comprehensive Procurement Evaluation: The selection process should not only focus on the product’s functionality but also include a thorough review of:

• Implementation Model: Assess the vendor’s approach to deployment and change management.
• Long-term Support and Customer Service: Ensure the vendor has robust mechanisms to address future challenges and maintain compliance, as well as a state user group for providers to collaborate with vendors and advocate for ongoing investments in state-specific functionality.
• Integration Capabilities: Evaluate the system’s ability to integrate with other critical tools and technologies.

Vetting Integrated Care Solutions

A small handful of vendors have made meaningful investments in solutions designed for integrated care. These should be carefully vetted using best practices to ensure they support:

• Revenue Cycle Management: Seamless management of billing and financial processes that span behavioral health billing rules that are often based upon programmatic and episodic-based rules, and encounter-based primary care billing.
• Clinical Care Delivery: Clinical care delivery solutions must provide comprehensive tools that facilitate high-quality care through seamless collaboration across teams, enabling treatment planning that integrates behavioral health and physical health conditions. The solution should robustly support the “golden thread” principle, ensuring assessment results such as diagnoses, problem lists, and identified needs dynamically populate an interdisciplinary treatment plan, while progress notes directly link to specific objectives within the plan for cohesive care documentation. To achieve true integration, the solution must also accommodate encounter-based care typical of primary care settings, offering comprehensive support for workflows such as chronic disease management, preventive care, and well visits.
• Regulatory Compliance: Adherence to federal, state, and country-specific reporting requirements including HRSA and state reporting, 21st Century Cures Act and 42 CFR Part 2.
• Negotiation for Customization: In cases where critical functionality is missing, organizations may need to negotiate for enhanced features during the contracting process. For example, county-specific or state-mandated reporting tools could be considered non-negotiable “table stakes” for moving forward.
• Pressure Testing the Solution: Conduct rigorous testing during the procurement process to validate the system’s ability to meet all organizational needs. This includes simulating real-world use cases to ensure the system can handle complex scenarios like integrated care coordination, compliance, and reporting. Conduct thorough demonstrations and testing to validate the system’s performance in real-world scenarios, such as ECM workflows or 42 CFR Part 2 compliance.
• Plan for Scalability: Ensure the selected system can evolve with your organization’s needs, particularly as regulations and care delivery models continue to shift.

Why a Detailed Procurement Process Matters

In states with complex regulatory and operational ecosystems like California or New York, the stakes for selecting the right EHR partner are even higher. The procurement process should be exhaustive, involving:

• Detailed Request for Proposals (RFPs) tailored to the organization’s unique requirements.
• Demonstrations of the technology in action, including customized use cases.
• References and case studies from similar organizations.

Emerging Statewide Initiatives

CalMHSA (California Mental Health Services Authority):

CalMHSA is a joint powers authority representing California counties, cities, and local mental health organizations. It was established to create a unified, collaborative approach to addressing statewide mental health needs. CalMHSA focuses on initiatives such as prevention and early intervention programs, crisis services, and other behavioral health priorities, aiming to improve outcomes for communities across California.

CalMHSA’s Electronic Health Record (EHR) initiative is designed to modernize and standardize behavioral health data systems across multiple counties in California. Key goals of the initiative include:

• Improved Interoperability: Ensuring seamless sharing of patient information among counties and providers, fostering better care coordination.
• Regulatory Compliance: Adhering to federal and state mandates, such as the 21st Century Cures Act and data privacy laws like HIPAA and 42 CFR Part 2.
• Standardization: Developing uniform clinical forms, workflows, and practices to improve efficiency and outcomes.
• County Collaboration: Supporting counties in adopting advanced, configurable EHR systems that meet local needs while enabling statewide alignment.

By partnering with Streamline SmartCare, CalMHSA is supporting 25  counties with a single EHR  to enhance care delivery, streamline operations, and foster a more integrated behavioral health system.

Catalyst Program by Kings View:

Kings View collaborated with an EHR vendor, and developed a program and managed services offering to provide solutions to other organizations supporting county-specific requirements  As of July 2023, 17 California counties have successfully implemented the Credible Electronic Health Record (EHR) platform through the partnership between Kings View Professional Services and Qualifacts.

Sources:

https://www.calmhsa.org/semi-statewide-ehr/

https://2023.calmhsa.org

https://www.newswire.com/news/qualifacts-credible-announces-california-partnership-with-kings-view-21365776?utm_source=chatgpt.com

Conclusion: Charting a Path Forward

Selecting an EHR in today’s behavioral health and integrated care landscape is not just a technical decision—it’s a strategic commitment to delivering quality care amidst regulatory complexity and evolving healthcare needs. While no single solution can address the diverse requirements of organizations serving FQHC and CMHC/CCBHC populations while also supporting all California Medi-cal requirements perfectly, a well-executed procurement process can yield a system that aligns closely with an organization’s goals.

By prioritizing integration, scalability, whole-person care provision, and compliance, and by fostering strong vendor partnerships, providers can position themselves for long-term success. Additionally, ongoing advocacy for innovation and affordability in the EHR market will be essential to overcoming barriers and enabling equitable access to advanced technology for smaller organizations.

Though the path to the ideal EHR solution is challenging, it is also an opportunity to rethink how technology supports whole-person care. With thoughtful planning and a commitment to collaboration, organizations can leverage EHR systems not just as tools for compliance, but as catalysts for innovation and better outcomes in behavioral health care.

About Behind the Screens in Behavioral Health™

Behind the Screens in Behavioral Health is a storytelling series that uncovers real-world scenarios where behavioral health technology—or the people and processes tied to its implementation—fell short. Each post dives into what went wrong, whether due to software functionality gaps or operational challenges, examines the impact on the business, and offers actionable solutions to address these issues. The series aims to provide clarity, spark innovation, and inspire meaningful improvements in the behavioral health industry.

Core Principles

This series is guided by principles drawn from the traditions of Alcoholics Anonymous (AA)—anonymity, shared learning, and independence—tailored to the unique needs of the behavioral health field:

• Anonymity: Stories are fictionalized and anonymized to protect individuals and organizations, creating a judgment-free space for shared learning.
• Vulnerability and Authenticity: Growth begins with honest reflection. Challenges are explored constructively, paving the way for innovation.
• Solution-Focused Dialogue: Each story emphasizes actionable solutions to inspire meaningful improvements in the field.
• Independence and Integrity: Vendor-neutral consultancy ensures insights are free from external influence.

Disclaimer

The scenarios and examples in this series are fictionalized for educational purposes. Any resemblance to specific organizations or individuals is purely coincidental. While inspired by AA principles, this series is not affiliated with or endorsed by AA. Stories are fictionalized to protect confidentiality while staying rooted in real-world scenarios.

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