As we move forward into 2025, we’ve been looking back upon 2024 and want to express how much gratitude we have for you, your commitment, and your participation in PHMI.
You are all critical to the success of this initiative. From our participating Community Health Centers (CHCs), to our coaches and subject matter experts, implementation partners, PHMI Program Office, and all our stakeholders, it truly takes a large and robust village to implement this Initiative.
Nearly two years into PHMI almost all 32 CHCs in the cohort have achieved their minimum standards in the four “Building the Foundation” competencies needed for successful population health management. These include empanelment (fostering relationships between patients and their providers), data quality and reporting, developing a business case for sustainability, and designing a team-based approach to care. And now, the majority of CHCs are focusing on their Populations of Focus.
Additional highlights from this past year include:
- Publication of our web-based Building the Foundation and Populations of Focus implementation guides, along with our Clinical Guidelines.
- Completed the third Population Health Management Capabilities Assessment Tool (PhmCAT) assessments and results from preliminary evaluation. CHCs are leveraging their results to update their 2025 workplans.
- The seven CHCs that opted to implement the PHMI Platform have completed most of their data acquisition, configuration, training and testing activities, and are preparing to “go live” with the Platform in early 2025.
- Launch of the PHMI Learning Action Network, providing monthly webinars and in-person Regional Learning Sessions, with robust peer interaction, excitement, and satisfaction for the breadth of PHMI resources.
- Working closely with our Practice Transformation partners to strengthen communication and effective integration and refinement of our CHC resources, including: coaching; an expanded network of subject matter experts including equity, quality improvement, workforce development; and health information technology. We aim to provide you meaningful resources at the right time, when you need them.
- A summary of PHMI Evaluation Preliminary Findings, reflecting progress through May 2024.
During one of our November meetings, we celebrated our CHCs’ progress, and Kiran Singh, Chief of the Incentive Programs Section within the Value-Based Payments Branch at DHCS, said, “I want to express how important and imperative it is that Population Health Management Initiative efforts are at the foundation of a lot of other efforts within the state. It's a proud moment to watch those efforts unfold.”
It’s important to remember, that at the start of implementation in 2023, no CHCs were meeting the minimum standards, whereas today, after more than 2,300 hours of evidence-based, locally tailored coaching, the CHCs are meeting 94% of the standards and 31 of 32 CHCs can report required quality data to the state. “I’m proud of our growth in case management, data quality, and so much more,” Michelle Hill, quality improvement manager at Long Valley Health Center in Mendocino County, said during the meeting. Demetrio Cardenas from Via Care Community Health Center in Los Angeles added, “I’m proud of the evolution of our quality department in our organization.” Other participants shared similar sentiments and recognized their evolution under the program is improving patient care.
PHMI Priorities for 2025
As we dive into this next year of important work, our 2025 priorities for the Initiative are around:
- Coaching CHCs to support sustainability and spread of successful interventions
- Leveraging our CHC cohort to address systemic barriers in population health management
- Creating plans for 2026 and beyond based on CHCs’ needs
- Supporting the expansion of the PHMI Platform for additional CHCs
- Enhancing PHMI Platform functionality
We’re also very proud of all the growth and progress thus far and look forward to continuing our work with you all!