California Medicaid is going value-based. Meet the woman leading the charge in Orange County

It's been just under a month since Kelly Bruno-Nelson was named executive director of Medi-Cal and CalAIM at CalOptima, a public health insurance agency in Orange County, Calif. that serves low-income children, adults, seniors and people with disabilities. 

Ms. Bruno-Nelson sat down with Becker's to discuss the second part of her new title, which is key to understanding the direction she plans to take the county's largest payer.

With the first reforms only beginning this past January, ​the California Advancing and​ Innovating Medi-Cal plan, or CalAIM, is a multiyear strategy to transform the state's Medicaid system to become more integrated with social services and create a new delivery system through value-based initiatives and payment reform. That's exactly what Ms. Bruno-Nelson will be tasked with for the nearly 900,000 Medi-Cal members CalOptima serves.

"We know that 80 percent of a person's ability to be healthy is predicated on social conditions or social determinants of health, and 20 percent is just the nuts and bolts of medical services," she said. "CalAIM recognizes that nuance and says, we shouldn't be separating these two buckets, we should be bringing these two buckets together."

But what exactly is a self-described fish out of water with no insurance experience doing at one of the largest public health plans in the most populated state in the nation?

"This is a health plan that recognizes that it not only needs to, in a very basic sense, fund community-based organizations — it needs to partner with community-based organizations," Ms. Bruno-Nelson said. "The best way to do that is to bring somebody from the outside in who's actually done the work on the other side. And that is exactly who I am." 

For more than 25 years, Ms. Bruno-Nelson has been directly involved in improving the health of vulnerable populations across Southern California through her work with healthcare and social organizations.

Before CalOptima, she was president and CEO of the National Health Foundation, a Los Angeles-based nonprofit that works to improve the health of underserved communities by addressing health disparities rooted in social determinants of health. Prior to that, she was vice president of ONEgeneration in Van Nuys, an intergenerational program of adult day care and child care that brings together seniors and young children through mutually beneficial relationships.

Through her work with nonprofits, Ms. Bruno-Nelson also contracted with six different health plans to provide CalAIM services to members.

Still, being on the other side of the equation doesn't mean transforming a fee-for-service-based public health plan to more value-based, whole-person care isn't a monumental task. 

"The challenge is that it's 900,000 people. It's kind of like, how do you eat an elephant in one bite?" she said. 

The plan to begin chipping away at the elephant bite-by-bite is to first evaluate how many community-based organizations are operating in the area and how their services align with the goals of CalAIM. Then, it's about asking how CalOptima can best support those ongoing services.

"Our members are already receiving services all throughout Orange County. All we have to do is contract with the folks that are already providing it," Ms. Bruno-Nelson said. "Then our money and our resources can help build their infrastructure, as opposed to trying to come from the top down."

One of the initiatives and priorities of CalAIM is to collect better data. The problem is that Orange County has at least four different systems collecting information from CalOptima members, so it can be difficult for a single carrier to understand what and who has interacted with a specific individual. For example, CalOptima is not currently integrated with the Orange County Coordinated Entry System, or an organizational process of connecting those at-risk of or experiencing homelessness with available services, including housing, in the community.

"We need a journey map of a person in Orange County. If you start with one person, how do they make it through the system and how many systems do they end up in," Ms. Bruno-Nelson explained. "That's where we can figure out how to bring them together. I don't know that anyone's ever been able to completely do that."

Ultimately, the goal is to create and strengthen the county's safety net through an infusion of resources already available. That may look as small as expanding medically tailored food services to include an entire family to changing the parameters of who can and cannot receive a housing deposit from Medi-Cal.

"I'm hoping that's what CalOptima comes to be known for — infusing dollars into the community and giving the power back to our communities," Ms. Bruno-Nelson said.

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