PATH Collaborative

The CPI initiative provides funding for regional collaborative planning efforts to support the implementation of Enhanced Care Management (ECM) and Community Supports.

The Santa Cruz County CPI group is composed of stakeholders that work together to identify, discuss, and resolve topical implementation issues, and share best practices. We identify how Providing Access and Transforming Health (PATH) and other CalAIM funding initiatives – including the Technical Assistance Marketplace – may be used to identify and address implementation and sustainability needs and gaps.

Benefits to participating in the Santa Cruz County PATH Collaborative

Enhanced collaboration across entities to improve the delivery of ECM and Community Supports
Best practice sharing, including coaching from state and national experts
Increased quality improvement capacity across team members
Access to a peer learning network focusing on capacity development and training, data sharing strategies, cross-sector care coordination, and other topics of focus

As the facilitator selected for the Santa Cruz County PATH Collaborative, HIP hosts and facilitates convenings, including our monthly Collaborative meetings as well as the Enhanced Care Management and Community Supports workgroup meetings. HIP works with participants to develop programmatic activities contributing to CalAIM’s whole system, a person-centered approach to care.

Program Committees & Meeting Details

Community Partners

PATH Collaborative Resources

The Santa Cruz County PATH Collaborative Resources page serves as a centralized hub for tools, materials, and learning opportunities that support CalAIM PATH implementation and collaboration across the county, including PATH CPI Monthly Meeting resources, Learning Circle session materials, access to the Santa Cruz Provider Directory, sustainability-related resources, and relevant materials developed outside of HIP.

If you have any questions about the resources on this page, please contact us at path@hipscc.org.

Santa Cruz path cpi monthly meetings

As the facilitators of the Santa Cruz County PATH Collaborative, the Health Improvement Partnership (HIP) organizes and leads monthly meetings to support the implementation of Enhanced Care Management (ECM) and Community Supports. These meetings bring together stakeholders to share insights, address programmatic opportunities, and develop activities that align with CalAIM’s whole-person, system-focused approach to care.

CPI monthly slide decks

Sustainability Resources

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.Resources are organized by topic area to make it easier to identify tools most relevant to your organization’s current needs.

Santa Cruz County Provider Directory

Last Updated: 10/30/2025

The following directory was developed using data received by the Central California Alliance for Health (the Alliance) and Kaiser Permanente (Kaiser). The sheet lists Community Supports (CS) and Enhanced Care Management (ECM) providers affiliated with the Alliance, as well as Community Supports and ECM providers affiliated with Kaiser Permanente. This directory is maintained and updated quarterly by HIP.

If you are a Community Supports or ECM provider, please ensure that your information is current on the directory, including whether you are providing in-person or telehealth services, accepting new clients, hours of operation, and the appropriate contact information.

CalAIM Provider Learning Circles

HIP offers ECM and Community Supports training as part of the CalAIM Provider Learning Circles. These trainings are designed to strengthen provider knowledge, build implementation capacity, and support high-quality care coordination for Medi-Cal members. Each session is tailored to the real-world needs of ECM and Community Supports providers, featuring practical tools, best practices, and opportunities for peer learning.

Please see our full playlist with all recordings available here.

5/22 Graduation, Step-Down & Disenrollment in ECM

Best practices for case closure, step-down planning, and administrative disenrollment across Populations of Focus. This training supports compliant, member-centered transitions and protects program integrity.

5/1 Collaborative Care Planning in ECM

Guidance on developing collaborative, measurable, and policy-aligned care plans that translate assessment findings into actionable goals and coordinated interventions. This training strengthens documentation of medical necessity, cross-system coordination, and transitional care planning to support compliance.

4/24 Managing ECM Coverage Transitions

Practical guidance on managing coverage gaps, enrollment changes, and churn while maintaining continuity of care and regulatory compliance. This training supports program sustainability and protects both members and providers during enrollment transitions.

4/3 Screening, Eligibility & Risk Identification in ECM

Structured approaches to eligibility screening, risk stratification, and pre-service chart review to ensure appropriate enrollment and prevent duplication of services. This training strengthens compliance, supports accurate enrollment decisions, and reduces audit vulnerability.

3/20 ECM Documentation & Progress Notes

Practical guidance on writing audit-ready progress notes that demonstrate medical necessity, coordination intensity, and measurable impact across all Populations of Focus. This training strengthens the connection between assessments, care plans, and interventions while covering required documentation elements, outreach efforts, and strategies to avoid common audit risks.

3/6 Ethical Decision-Making and Best Practices in ECM

Guidance on ethical decision-making, professional boundaries, and best practices in ECM service delivery. This training translates core ethical principles into real-world scenarios, helping case managers navigate scope of practice, medical necessity, and documentation while protecting members, staff, and programs.

12/12 Case Management Progress Notes: Clear, Skill-Based, and Client-Centered Documentation

This training strengthens progress note clarity and quality using a skill-based documentation approach that reflects the Golden Thread—connecting identified needs, care plan goals, interventions, and outcomes. The session emphasizes trauma-informed practices that elevate client voice, reduce stigmatizing language, and clearly capture case management value.

12/5 Strengthening Care Plans through SDOH: Screenings, Z-Codes and Documentation of Medical Necessity

This training strengthens case managers’ ability to identify, document, and address SDOH within ECM care planning. Participants will learn to use standardized screening tools, apply ICD-10 Z-codes, and connect identified needs to measurable goals and interventions using the Golden Thread approach that supports continuity and whole-person care.

11/14 Comprehensive Assessment, Care Plans, & Transition of Care

Guidance on conducting trauma-informed assessments and converting identified needs into measurable care goals using the Golden Thread approach—linking assessment, care planning, interventions, and transitions. Participants will practice translating findings into action and documenting intentional transitions that support continuity and client empowerment.

10/31 Quality Documentation: Why it Matters

Practical guidance for lead case managers to enhance documentation quality, clarity, and impact using the Golden Thread approach—connecting assessment, care planning, interventions, and encounter notes. Participants will learn how effective documentation tells the client’s story, demonstrates medical necessity, and supports coordinated, person-centered care.

10/17 Working with Children and Youth in ECM

This training introduces providers to effective practices for supporting children and youth within the ECM framework. Learn about community partnerships, outreach strategies, and how to develop assessments and care plans tailored to young clients.

9/30 Medi-Cal Policy and SDOH Impacts on CalAIM Services

Strategic insights for ECM and Community Supports providers to navigate Medi-Cal policy changes and address social determinants of health impacting CalAIM services. Participants will explore proactive strategies to reduce coverage loss, preserve care access, and maintain service continuity for vulnerable populations through enhanced cross-sector collaboration and coordination.

Slide Deck

8/27 Closed Loop Referrals

Comprehensive training for ECM providers on DHCS Closed-Loop Referral (CLR) requirements and implementation strategies. Participants will review essential definitions, timelines, and Managed Care Plan tracking protocols while exploring practical approaches to strengthen referral workflows, improve cross-system communication, and reduce service gaps for members through enhanced coordination and shared accountability.

Slide Deck

7/30 Data Exchange Framework

Essential guidance for providers on leveraging the California Data Exchange Framework (DxF) and Data Sharing Agreement (DSA) to enhance care coordination and continuity. Participants will explore secure data sharing protocols, review CalAIM use cases including automated referrals and hospital notifications, and identify practical opportunities to reduce communication gaps.

Slide Deck

Program Staff

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.