Health equity is not a destination — it is a continuous practice of identifying where systems fail specific populations and redesigning those systems to produce different outcomes. At Carenodes, our work is organized around four strategic pillars that we believe are necessary and sufficient for making meaningful progress on health equity in California's Medi-Cal ecosystem.
Health equity work without data is advocacy. Health equity work with data is strategy. Carenodes invests heavily in data infrastructure — claims analytics, social determinants screening data, community health worker encounter data, and quality metric tracking — that allows us to identify where disparities exist, quantify their magnitude, and measure whether interventions are closing gaps. We work with managed care plans and lead entities to build the data pipelines and reporting dashboards that make equity measurement a routine operational function rather than an annual exercise.
The social determinants of health — housing, food security, transportation, economic stability — are not addressable by the healthcare system alone. Carenodes builds and maintains relationships with community-based organizations, housing authorities, food banks, workforce development programs, and faith communities that are essential partners in addressing the upstream drivers of health inequity. Our network of cross-sector partners is a core asset that we bring to every managed care plan and lead entity engagement.
CalAIM is the most significant Medicaid reform in California in a generation, and its design — particularly the Enhanced Care Management and Community Supports programs — is explicitly oriented toward high-need, high-cost populations that are disproportionately communities of color. Carenodes helps organizations use CalAIM not just as a revenue opportunity but as a structural mechanism for advancing health equity: targeting ECM enrollment toward the highest-need members, designing Community Supports utilization to address documented social needs, and using the program's quality metrics to hold plans and providers accountable for equity outcomes.
Access to care is necessary but not sufficient for health equity. Carenodes works with providers and plans to address the full spectrum of access barriers — geographic, linguistic, cultural, financial, and systemic — that prevent Medi-Cal members from receiving the care they need. This includes supporting the development of culturally and linguistically appropriate services (CLAS), advocating for network adequacy standards that reflect actual access rather than theoretical availability, and designing care coordination models that meet members where they are rather than requiring them to navigate complex systems on their own.
The Intersection of Data and Equity
One of the most persistent challenges in health equity work is the gap between what organizations believe about their performance and what the data actually shows. Managed care plans routinely report strong quality metric scores while simultaneously serving populations with significant unmet social needs and measurable disparities in clinical outcomes. The disconnect is not dishonesty — it is a measurement problem.
Carenodes addresses this by stratifying quality metrics by race, ethnicity, language, and geography — a practice that DHCS is increasingly requiring but that many plans and providers have not yet operationalized. When you stratify HEDIS measures by race and ethnicity, the aggregate score often masks significant disparities: a plan with an overall diabetes control rate of 65% may have a rate of 45% among Black members and 78% among white members. The aggregate number is not wrong — it is just not useful for equity work.
CalAIM as a Structural Equity Mechanism
The design of CalAIM reflects a deliberate policy choice to use Medicaid managed care as a vehicle for addressing social determinants of health. The Community Supports program, in particular, represents a significant expansion of what Medicaid will pay for — housing deposits, medically tailored meals, sobering centers, and other services that address the social conditions that drive health outcomes.
But the equity potential of CalAIM will only be realized if the organizations implementing it — managed care plans, lead entities, and CBOs — are intentional about targeting services toward the populations with the greatest need and the most significant disparities. Carenodes works with these organizations to build the targeting criteria, outreach strategies, and community partnerships that translate CalAIM's equity intent into equity outcomes.