HRSN Services in California: How CalAIM Delivers Social Care Through Medi-Cal

California has built one of the most ambitious frameworks in the country for addressing health-related social needs (HRSN) at scale. Through the California Advancing and Innovating Medi-Cal (CalAIM) initiative, the state has embedded HRSN response directly into Medi-Cal managed care, moving social care from a charitable add-on to a funded, contracted, and increasingly audited part of how Medi-Cal members receive care.

If you're an FQHC, ACO, community-based organization (CBO), or Medi-Cal Managed Care Plan (MCP) operating in California, this is the operational landscape you're working in. Here's what HRSN services in California actually look like: how they're structured, how they're funded, how they're delivered, and what the closed-loop referral mandate means for your organization right now.

What CalAIM Is and Why It Matters for HRSN

On January 1, 2022, the California Department of Health Care Services (DHCS) launched CalAIM, a five-year plan to make Medi-Cal more equitable, coordinated, and person-centered. It focuses on addressing complex care for high-needs populations, including individuals experiencing homelessness, serious mental illness, or substance use disorders, and encourages Medi-Cal managed care plans to address social determinants of health through preventative upstream interventions. This builds on broader federal Medicaid flexibility that allows states to cover defined HRSN services through managed care and Section 1115 demonstrations. CalAIM is one of the most mature implementations of that authority.

Following changes to federal CMS guidance in early 2025, DHCS confirmed that existing approvals, including California's Section 1115 waivers supporting Community Supports, remain unaffected. DHCS, Medi-Cal managed care plans, and Medi-Cal providers continue to provide Community Supports to address members' HRSNs, help them live healthier lives, and avoid higher, costlier levels of care.

Building the policy framework was only the first step. Delivering these services across hundreds of organizations requires referral infrastructure capable of connecting plans, providers, and CBOs in real time, which is where Community Supports and Enhanced Care Management (ECM) come in.

The 14 CalAIM Community Supports Services

Community Supports are the primary service delivery mechanism for addressing many HRSNs within CalAIM, working alongside Enhanced Care Management (ECM). They consist of 14 DHCS-approved services that Medi-Cal MCPs may offer to members whose social needs are driving avoidable use of higher-cost clinical care.

Community Supports operate as In Lieu of Services (ILOS), meaning they are cost-effective substitutes for standard Medi-Cal benefits. A member who would otherwise require repeated emergency department visits or a hospital readmission due to housing instability can instead receive housing navigation support or recuperative care through a CBO funded through the MCP, documented in the care plan, and tracked to a known outcome.

California has approved 14 Community Supports services that Medi-Cal MCPs may offer to eligible members. These services span housing stability, nutritional support, recovery care, daily living assistance, environmental health, and behavioral health, each designed as a cost-effective alternative to higher-cost clinical care for Medi-Cal members whose health is directly affected by unmet social needs.

Housing

Housing transition navigation services, housing deposits, and tenancy and sustaining services that help members find, secure, and maintain stable housing to prevent homelessness and reduce avoidable utilization of acute care.

Recovery and respite

Recuperative care (medical respite), short-term post-hospitalization housing, caregiver respite services providing safe transitional settings for members recovering from illness or injury who lack stable housing, and relief for caregivers of high-need members.

Daily living and independence

Day habilitation programs; personal care and homemaker services; nursing facility transition and diversion to assisted living facilities; community transition services from nursing facilities to home supporting members in living independently in community settings rather than higher-cost institutional care.

Environmental supports

Environmental accessibility adaptations (home modifications), asthma remediation addressing unsafe or unhealthy home conditions that directly contribute to avoidable emergency visits and chronic disease exacerbation.

Nutrition

Medically supportive food and medically tailored meals that provide clinically appropriate nutrition for members managing serious health conditions in which food access directly impacts treatment outcomes.

Behavioral health

Sobering centers are short-term facilities that provide a safe, supervised setting for individuals experiencing acute alcohol or drug intoxication, serving as a cost-effective alternative to emergency department visits. DHCS currently exempts Sobering Centers from Closed-Loop Referral requirements due to the unique, short-duration nature of the service.

MCPs are not required to offer all 14; they select which Community Supports to make available based on their member population, county capacity, and CBO network. However, DHCS has strongly encouraged MCPs to offer a robust menu, particularly for members with the most complex health challenges. Members enrolled in Enhanced Care Management (ECM), CalAIM's intensive care management benefit for the highest-need members, should have their Community Supports coordinated through their ECM lead care manager.

How HRSN Services Are Accessed in California

HRSN services through CalAIM are delivered entirely through Medi-Cal managed care, not through fee-for-service Medi-Cal. The pathway to services runs through the MCP, not directly through DHCS or a state office.

In practice, the workflow looks like this: A care team member—a primary care provider, community health worker, ECM lead care manager, or FQHC clinic coordinator—screens a Medi-Cal member for HRSN using a validated tool such as PRAPARE or the AHC HRSN Screening Tool. If a need is identified, it is documented in the member's care plan, typically with an ICD-10-CM Z-code (Z55–Z65). A referral is then generated to a CBO in the MCP's network that can deliver the appropriate Community Support. The MCP is responsible for tracking the referral through to a DHCS-defined Known Closure—confirmation of whether the member received the service, declined it, or no longer needs it.

That final step, the Known Closure, is what makes this a closed-loop referral system. And it is now the center of California's HRSN compliance requirements for the services it currently covers.

The Closed-Loop Referral Mandate: What Changed in 2025

Effective July 1, 2025, Medi-Cal Managed Care Plans were required to implement Closed-Loop Referral (CLR) for Enhanced Care Management (ECM) and Community Supports, the two priority services for which DHCS currently requires closed-loop tracking, with other services expected to follow over time. DHCS defines a Closed-Loop Referral (CLR) as a referral initiated on behalf of a Medi-Cal Managed Care member that is tracked, supported, monitored, and results in a Known Closure. Alongside the July 1, 2025 effective date, DHCS updated the JSON data submissions that MCPs use for ECM and Community Supports reporting to incorporate CLR monitoring data, thereby building DHCS's oversight directly into the infrastructure MCPs already use.

This is a significant operational shift. Before the CLR mandate, an MCP could generate a referral to a CBO without any systematic obligation to verify whether the member had ever connected with services. Under the current requirements, that is no longer acceptable for ECM and Community Supports referrals.

For ECM and Community Supports, MCPs are now required to:

• Track referral status with service providers on at least a monthly basis
• Notify referring entities and members of referral status updates, including authorization decisions and referral loop closures
• Respond to member or referring-entity inquiries within one business day
• Submit CLR data to DHCS through updated JSON reporting tied to existing ECM and Community Supports data infrastructure
• Document a Known Closure for every referral initiated to ECM or Community Supports

For CBOs, this means they must be integrated into a data-sharing infrastructure able to receive structured referrals, update referral status, and communicate outcomes back to the MCP. Organizations that cannot participate in a closed-loop system risk being deprioritized or excluded from MCP networks entirely for these services.

Frequently Asked Questions

The Operational Gap: Where HRSN Service Delivery Breaks Down

California's framework is sophisticated. The challenge is execution.

MCPs are contracting with dozens, sometimes hundreds of CBOs across their service counties. Each of those CBOs may operate different intake workflows, serve different capacity levels, and use different data systems. A referral sent from an FQHC care coordinator to a housing navigation CBO through one plan's system may look completely different from a referral sent by an ECM lead care manager through another plan's system.

Without a shared, interoperable closed-loop referral infrastructure, the result is fragmentation: referrals that are technically sent but never confirmed received, CBOs that have no channel to communicate back, and MCPs that struggle to compile the CLR data DHCS requires. Community members fall through the gap between a positive screen and the actual help they receive, and the data never reflects what happened. Early evaluation work on the implementation of Community Supports has identified this kind of operational variation as a key factor in the consistency with which members are connected to services.

This is the operational problem that determines whether California's HRSN investment actually reaches the people it was designed to serve.

How GridSocial Supports California HRSN Delivery

GridSocial is a closed-loop referral management platform purpose-built for MCPs, FQHCs, ACOs, ECM providers, and CBOs that deliver HRSN services under CalAIM.

GridSocial connects every step of the DHCS-required workflow in one place. Care teams screen members and document HRSN needs with the right Z-codes. Referrals are routed to the appropriate CBO based on service type, geography, and capacity, with real-time status updates returned throughout the referral lifecycle. CBOs receive structured, complete referral information and update status in real time. MCPs get the tracking, monitoring, and Known Closure documentation they need to support DHCS CLR compliance for ECM and Community Supports, along with the reporting data that demonstrates it.

For FQHCs and ECM providers, instead of relying on paper handouts or disconnected follow-up processes, care teams can track whether members successfully connect with services and intervene when referrals stall. For CBOs, it means a streamlined intake process and a direct, documented line back to the referring entity. For health plans, it means auditability: the timestamped, closed-loop record that demonstrates Community Supports are being delivered as contracted, at the member level, every time.

California has built the policy framework. DHCS has set the compliance timeline for ECM and Community Supports. The organizations that build the operational infrastructure to execute it efficiently, at scale, with every referral tracked to a Known Closure are the ones that will lead in this environment.

HRSN isn't a checkbox in California. It is a contracted obligation, a compliance requirement, and increasingly, a measure of whether a plan or provider is actually serving its members. GridSocial makes that obligation achievable.

Ready to meet California's CLR requirements and close every HRSN referral loop? See how GridSocial helps California MCPs manage compliant, closed-loop referrals from intake to outcome tracking.

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References

1. California Department of Health Care Services. Community Supports — CalAIM. calaim.dhcs.ca.gov

2. DHCS Stakeholder News. Community Supports in California Remain Unaffected. March 10, 2025. dhcs.ca.gov

3. DHCS. Closed-Loop Referral Frequently Asked Questions. dhcs.ca.gov

4. DHCS. Closed-Loop Referral Implementation Guidance — All-Comer Webinar. February 2025. dhcs.ca.gov

5. DHCS. Community Supports: Select Service Definition Updates. February 2025. dhcs.ca.gov

6. UCLA-RAND. Evaluation Design for CalAIM Community Supports. October 2024. dhcs.ca.gov

7. Centers for Medicare & Medicaid Services. Coverage of Health-Related Social Needs (HRSN) Services in Medicaid and CHIP. medicaid.gov