The PhmCAT Helps CHCs and Coaches Come to Consensus on the Work Ahead

The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multi-domain assessment that is used to understand current population health management capabilities of primary care practices. It can help identify their strengths and opportunities for development. The tool was developed by a multi-stakeholder workgroup that included the California Department of Health Care Services (DHCS), California Primary Care Association (CPCA), Regional Associations of California (RACs), and Health Plan representatives and Population Health Management Initiative (PHMI) staff.

The PhmCAT includes 50 survey questions organized into 8 domains identified by the multi-stakeholder workgroup as critical for effective population health management (see Figure 1). Questions are rated on a 10-point scale where one is low/not in place and 10 is high/in place.

PhmCAT domains
Figure 1. PhmCAT domains


PhmCAT Administration to PHMI’s Cohort of 32 CHCs and Analysis

In spring 2023, the PhmCAT was administered to a multidisciplinary team of individuals in each of the 32 community health centers (CHCs) participating in PHMI. The aim was to assure input from a variety of perspectives, including executive leadership, quality improvement, and care team providers and staff. After individuals completed the tool, their scores were averaged for each question. Coaches facilitated consensus conversations with each CHC team where there was wide variation in individual responses or where individuals held differing opinions about scoring.

Overview of PhmCAT administration and reporting
Figure 2. Overview of PhmCAT administration and reporting


CHCs received reports that included their average scores along with overall averages across all the participating CHCs for comparison. These reports were used by practices and their coaches to identify priority areas to begin work on. Additional stakeholders, including CPCA and RACs, also received summary-level reports that included:

  • Domain average scores
  • Item-level scores
  • Areas of opportunity and strength (i.e., highest and lowest scores) across and within domains
  • Domain average scores by health center size and region

Figures 3 and 4 provide top areas of strength and opportunity at the initiative level based on highest and lowest average scores. The top two areas of strength across all domains included 1) organization screens patients to understand behavioral health conditions; and 2) when patients are overdue for chronic and/or preventive care, the practice will contact and ask them to come in for care.

The top two areas of opportunity included 1) recruitment, hiring, and development of a workforce that reflects the populations served; and 2) self-management support provided by trained care team and designed to be culturally and linguistically concordant to patient need.

Areas of strength
Figure 3. Areas of strength


Areas of opportunity
Figure 4. Areas of opportunity


What’s next?

The tool will be administered again in late fall 2023 and annually thereafter to inform support needed and monitor improvement over time. Reports will be generated and shared after each implementation of the PhmCAT.

Where can I get more information about the PhmCAT?

Learn more on our site or reach out to