Executive Summary

Overview and Purpose

California Advancing and Innovating Medi-Cal (CalAIM) represents a fundamental shift in the Medi-Cal delivery system, expanding the role of community-based organizations (CBOs) and non-clinical providers to address health-related social needs (HRSN) and advance whole-person, equity-centered care. The Community Health Worker/Promotor/Representative (CHW/P/R) benefit is a cornerstone of this transformation, formalizing and reimbursing a community-rooted workforce that has long operated outside traditional medical systems yet plays a critical role in reaching populations with the greatest barriers to care.

Since 2023, the San Diego Wellness Collaborative (SDWC) and its network of community-based partners have worked to operationalize the Medi-Cal CHW benefit in San Diego County amid limited state guidance, evolving managed care organization (MCO) requirements, and significant workforce and financial constraints. This evaluation assesses implementation experiences, early impacts, and sustainability considerations over approximately 30 months of implementation, spanning program launch, operational scaling, and emerging policy and workforce challenges.

This report presents findings from a learning-oriented, mixed-methods evaluation designed to document real-world implementation, generate actionable insights, and inform both local and statewide CalAIM implementation. Findings reflect data from surveys, key informant interviews, structured observations, and document review, with a particular focus on the value of CHW/P/R services and the role of SDWC as a Network Hub supporting community-based participation in Medi-Cal.

Three Distinct Phases of Implementation

Over the course of implementation, the CHW/P/R benefit evolved through distinct phases as community-based partners moved from program launch to sustainability planning. In the early phase (2023), stakeholders focused on foundational readiness questions, including role definition, workforce onboarding, and the feasibility of operating within Medi-Cal billing and compliance requirements. By the middle phase (2024), implementation realities revealed significant structural pressures, including low reimbursement, delayed payments, high administrative burden, and increasing workforce strain. In the later phase (late 2024–2025), conversations shifted toward long-term sustainability, equity, and policy advocacy, with growing recognition that CHW/P/R impact was well established but threatened by underfunding, inconsistent guidance, and the need for stronger system infrastructure and rate reform (see Appendix A).

Key Findings: Value and Impact of the CHW/P/R Benefit

CHW/P/Rs are essential to Medi-Cal’s ability to reach high-need populations.

Across data sources, CHW/P/Rs were consistently described as transformational and essential to engagement, trust-building, and continuity of care. CHW/P/Rs bring cultural humility, lived experience, and deep community trust—attributes often lacking in traditional clinical systems. Their work is particularly critical for Medi-Cal members experiencing trauma, housing instability, language barriers, immigration-related fear, and distrust of institutions.

CHW/P/Rs function as the connective tissue between health care and social systems.

CHW/P/Rs mitigate the complexity of Medi-Cal by explaining benefits in plain language, navigating health plans and community resources, coordinating appointments and transportation, and following up on referrals that frequently stall. This navigation function reduces administrative burden on clinical teams while increasing the likelihood that members actually access needed services.

The CHW/P/R role reinforces, not replaces clinical care.

While clinicians assess and diagnose, CHW/P/Rs reinforce care plans through ongoing, practical support. They help members translate clinical recommendations into actionable steps, accompany them to appointments, provide health education, and relay critical contextual information back to care teams. This role enhances care plan realism, responsiveness, and adherence.

Service demand and utilization increased as implementation stabilized.

Survey data show that CHW caseloads expanded substantially from 2024 to 2025, reflecting growing referrals, increased recognition of the CHW role, and rising system reliance on non-clinical supports. Service delivery remained consistently hybrid (phone and in-person), supporting engagement across diverse needs and settings. Importantly, the service mix remained stable over time, demonstrating strong alignment with CalAIM’s intended non-clinical benefit design and no evidence of role drift or medicalization.

Equity-centered, culturally responsive care is a defining contribution.

CHW/P/Rs’ cultural and linguistic alignment with the communities they serve improves equity, appropriateness, and effectiveness of care. They adapt engagement strategies to community norms, address stigma around mental health and social services, and honor traditional healing practices alongside Western medicine—an essential function for immigrant, refugee, and historically marginalized Medi-Cal populations.

Key Implementation Challenges

Despite clear value, the evaluation identified persistent and systemic challenges that threaten sustainability:

• Inadequate reimbursement rates that cover only direct CHW time while excluding supervision, administrative work, data reporting, outreach prior to consent, and travel.
• Delayed Medi-Cal payments, often 60–90 days or longer, forcing CBOs to front payroll costs and increasing financial risk.
• Workforce recruitment and retention challenges, driven by low compensation, high emotional labor, secondary trauma, role ambiguity, and lack of standardized training and certification pathways.
• Significant administrative burden for CBOs navigating multiple MCOs with inconsistent contracting, billing rules, and guidance.
• Persistent client engagement barriers, including housing instability, lack of technology, trauma histories, and distrust of institutions, requiring time-intensive, relationship-based approaches.

These challenges are structural rather than temporary and cannot be resolved through workforce effort alone.

Impact of the San Diego Wellness Collaborative and Neighborhood Networks

A central finding of this evaluation is that SDWC’s role as a Network Hub is foundational to successful CHW benefit implementation in San Diego County.

SDWC enabled CBO participation in Medi-Cal that would otherwise not have been feasible.

By providing centralized contracting, billing, compliance support, standardized workflows, referral management, and training, SDWC significantly lowered barriers to entry for CBOs—particularly smaller, culturally specific organizations with limited administrative capacity.

SDWC strengthened workforce stability and resilience.

Through Communities of Practice, reflective practice, peer learning, and clinical consultation, SDWC supported CHW/P/R well-being, mitigated burnout, and reinforced professional identity. These relational supports were consistently described as equally important as technical assistance.

SDWC facilitated shared learning, alignment, and advocacy.

SDWC convened CBOs, MCOs, clinicians, and other stakeholders to interpret evolving state guidance, surface implementation challenges, share best practices, and elevate frontline experience to system-level policy discussions. This collaborative model reduced duplication, accelerated problem-solving, and promoted greater consistency across a fragmented system.

SDWC advanced equity through community-rooted implementation.

By prioritizing culturally specific CBOs and relationship-based models, SDWC ensured that CalAIM services reached populations often excluded from traditional systems. SDWC functioned as a trusted intermediary, translating between state policy, managed care expectations, and community realities.

Conclusions and Implications

This evaluation demonstrates that CHW/P/Rs are critical infrastructure for CalAIM, advancing equity, improving engagement, and ensuring that investments in Medi-Cal translate into meaningful outcomes for high-need populations. However, current reimbursement and implementation models do not fully support the workforce or the organizations that employ them.

Sustaining the CHW/P/R benefit requires:

• Adequate reimbursement that reflects the full cost of service delivery
• Investment in workforce training, supervision, and well-being
• Administrative simplification and greater standardization across MCOs
• Continued support for Network Hub infrastructures like SDWC

The success of CalAIM’s CHW benefit depends not on program design alone, but on sustained investment in workforce, infrastructure, and equity-centered implementation. Without these supports, the system risks undermining one of its most effective tools for achieving whole-person, equitable care.