PATH Collaborative Resource Hub
The PATH Provider Resource Hub brings together training, recordings, forms, and practical tools to support ECM and Community Supports providers across Santa Cruz County. Organized by topic, these resources support service delivery, care coordination, and organizational sustainability and will remain accessible after the PATH Collaborative concludes on December 31, 2026.
Screening, Outreach, & Member Engagement
Explore trainings and practical tools to help providers indentify eligible members, strengthen outreach, and build trusting relationships that support ongoing engagement in ECM. Materials include screening and chart review checklists, guidance for working with children and youth POF, and ethical considerations for person-centered delivery.
trainings
Assessments, Care Planning, & Documentation
Access trainings, templates and examples to support comprehensive assesments, collaborative care planning, and clear, meaningful documentation. Resources help providers connect identified needs with member goals, interventions, and progress, with guidance on documenting medical necessity, incorporating social determinants of health, and coordinating care transitions.
trainings
- Collaborative Care Planning in ECM [Slide Deck]
- ECM Documentation & Progress Notes [Slide Deck]
- Case Management Progress Notes: Clear, Skill-Based, and Client-Centered Documentation [Slide Deck]
- Strengthening Care Plans through SDOH: Screenings, Z-Codes and Documentation of Medical Necessity [Slide Deck]
- Comprehensive Assessment, Care Plans, & Transition of Care [Slide Deck]
- Quality Documentation: Why it Matters [Slide Deck]
Documents
- Care Plan Template – Adult
- Care Plan Template – Children & Youth
- Care Plan Updates Template
- Comprehensive Children and Youth Assessment Tool
- ECM Care Plan Update & Transition Checklist
- Transitional Care Plan Template
- ECM Case Management Progress Note Guide
- ECM Documentation Sentence Starters Handout
- ECM Progress Notes Examples
- Five SMART Goal Examples (SDOH-BASED)
- SDOH Z-Codes Quick Reference with Medical Necessity Examples
- SMART Goal Cheat Sheet
Coverage, Transitions, Graduation, & Disenrollment
Find guidance and tools to support members through coverage changes, gaps in enrollment, and transitions out of ECM. Materials include documentation templates, decision trees, and graduation and disenrollment forms to help providers plan next steps, coordinate follow-up support, and promote continuity of care.
trainings
Sustainability & Organizational Capacity
As Santa Cruz County providers continue planning for long-term sustainability, HIP has reviewed and organized tools and resources that may support Enhanced Care Management (ECM) and Community Supports implementation, operations, and planning.
These resources are intended to help providers strengthen referral networks, financial sustainability, workforce development, operational workflows, leadership, and data-informed decision making as we prepare for the next phase of CalAIM implementation.
Topics include budgeting and financial tracking, financial sustainability, staff training and development, leadership, and collaboration to support organizational planning and service delivery.
- Financial Sustainability
- CalAIM Budget Estimator Tool (Camden Coalition): Excel-based tool to estimate revenue, expenses, and margin; can support basic financial forecasting and scenario planning.
- ECM Payment Transition Calculator (Camden Coalition)Â The ECM Payment Transition Calculator helps Alliance ECM providers prepare for the shift from case-rate to Fee-for-Service billing beginning January 2027. It’s designed to help organizations pinpoint, well ahead of the transition, exactly how much their billing operations need to scale to stay financially healthy.
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Community Supports & Other CalAIM Resources
Find additional materials on Community Supports, related Medi-Cal benefits, and policy and funding developments that affect local CalAIM implementation. Resources include information on transitional rent, the Community Health Worker benefit, and state and county budget updates to support provider understanding and planning.
- Behavioral Health Services Act & Transitional Rent FAQ
- This FAQ clarifies the Behavioral Health Services Act (BHSA), Transitional Rent eligibility, and how ECM coordinates with County Behavioral Health and housing teams. Developed collaboratively with County Behavioral Health and Housing for Health, it addresses commonly asked provider questions about specialty versus non-specialty behavioral health services, County Behavioral Health access, eligibility criteria, and cross-system care coordination for shared members. .
- Community Health Worker (CHW) Benefit FAQ
This FAQ provides practical guidance on the Medi-Cal Community Health Worker (CHW) Benefit, including member eligibility, provider qualifications, documentation, billing, service limits, and Plan of Care requirements. It also clarifies how CHW services coordinate with Enhanced Care Management (ECM), including transitions to lower-intensity CHW support, and provides information about local CHW training opportunities through Cabrillo College.
INTREPID ASCENT – Step Up/Step Down A Guide to Non-Duplicative Intersections of ECM & CHW Services
This toolkit (developed by Intrepid Ascent) focuses on clarifying the key differences and similarities between ECM and CHW services, identifying where the two models naturally complement one another, and supporting organizations in considering how ECM and CHWs can be
deployed together as part of a broader service delivery and sustainability strategy.
- California State Budget – One Pager
- This one-pager provides an overview of California’s annual state budget process, including key players, timeline, and engagement opportunities for advocates. It explains the three types of state funds, the roles of the Governor, Legislature, and Department of Finance, and critical budget milestones from January through July.Â
- Santa Cruz County Budget – One Pager
- This one-pager outlines Santa Cruz County’s annual budget process, key decision-makers, and timeline from August through September adoption. It outlines the roles of the Board of Supervisors, County Executive Officer, and community members, and identifies multiple engagement opportunities. The resource includes practical advocacy tips for connecting budget priorities to local impact and directs readers to key county resources.
DHCS Resources Medi-Cal Fee-for-Service Transition
Access DHCS resources to help providers, community support partners, and members understand the transition from Medi-Cal managed care to Fee-for-Service. Materials inclujde member and provider FAQs, a transition fact sheet, policy guidance, and a webinar, and a tool to find doctors and services to support care navigation and continunity during the transition.
Funding Acknowledgement to DHCS
We thank the California Department of Health Care Services (DHCS) for its support of CalAIM initiatives. Santa Cruz County was awarded $28.7 million through CITED Round 3 grant funding to strengthen infrastructure and advance whole-person, equity-focused care for Medi-Cal members.