Populations of Focus

Adults Living with Chronic Conditions Guide

Version 3 – June 2026

Putting the Key Activities in Context

Person-centered population-based care

Each of the key activities advance one or more of the seven person-centered population-based care change concepts:

  1. Operationalize clinical guidelines.
  2. Implement condition-specific registries.
  3. Proactive patient outreach and engagement.
  4. Pre-visit planning and care gap reduction.
  5. Care coordination.
  6. Behavioral health integration.
  7. Address social needs.

FIGURE 1: PHMI IMPLEMENTATION MODEL

PHMI Implementation Model

The measures covered in this guide consist of Healthcare Effective Data and Information Set (HEDIS) measures designated as core and supplemental measures by PHMI. These measures can be considered outcome measures because there is ample evidence that improved timely screening rates and follow-up care improves overall population health outcomes for depression. All measures use standard HEDIS definitions and are aligned with California Advancing and Innovating Medi-Ca (CalAIM) and Alternative Payment Methodology (APM 2.0). For information about these measures, reference the PHMI Data Quality and Reporting Guide

PHMI selected two core and one supplemental measures of focus for adult chronic condition management, though practices can track others that feel important and relevant. This guide provides detailed guidance to improve your practice’s results on the measures selected by PHMI.

Core HEDIS Measures for PHMI

PHMI Populations of Focus

Measures

Adults Living With Chronic Conditions

Controlling High Blood Pressure
Percentage of 18- to 85-year-old people with hypertension whose blood pressure was adequately controlled (<140/90 mm Hg).

 

Comprehensive Diabetes Care
Percentage of 18- to 75-year-old people with diabetes whose hemoglobin A1c was not under control (>9%).

 

Supplemental HEDIS Measures for PHMI

PHMI Populations of Focus

Measures

All Adults

Adults’ Access to Preventive and Ambulatory Health Services
Percentage of members 20 years and older who had an ambulatory or preventive care visit.

 

The core and supplemental measures are part of a larger measurement strategy and learning system, as outlined in Appendix A: Sample Idealized System Diagram: Weaving Your Measurement Strategy and Learning System into Practice Operations. Key Activity 1: Convene a Multidisciplinary Implementation Team for Chronic Care Management outlines how your practice can develop a robust measurement system to support this work. In addition to quality assurance and monitoring, measures are also used during practice operations alongside other data for learning to:

  • Guide the actions of the multidisciplinary implementation team as it uses a systematic approach to decreasing inequities and support implementing key activities across the practice.
  • Support the care team’s efforts to advance population health and reduce care gaps through daily, weekly and monthly workflows, as well as continuously identify opportunities for improvement.

The PHMI Clinical Guidelines Advisory Group (CGAG) was established to create a standardized approach to review, adopt and promote established clinical guidelines in the PHMI cohort. For people with chronic health conditions, guidance includes controlling hypertension and comprehensive diabetes care. For more information please see the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus.

FIGURE 2: CLINICAL GUIDELINES: CONTROLLING HIGH BLOOD PRESSURE


Guideline source
Kaiser Permanente National Guideline Program (October 2021)

PHMI measure
Controlling High Blood Pressure

Guideline language

Blood pressure (BP) screening: Screen adults 18 years and older for high blood pressure.

  • In adults aged 18 to 39 years with blood pressure <130/85 mm Hg without other risk factors, screen every three to five years.
  • In adults 40 years and older and those at increased risk of high blood pressure, screen annually
  • Adults at increased risk include those who have blood pressure ≥130/85 mm Hg or are overweight, obese or Black/ African American.

Hypertension definition:

  • Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
  • Blood pressure readings equal to or higher than those in the first row of Figure 1 seen in the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus confirms the diagnosis of hypertension. Use clinical judgment if obtaining blood pressure outside the clinical setting is not possible. Automated office blood pressure (AOBP) measurements at more than two visits may be used.
  • Diagnose hypertension for blood pressure ≥180/110 mm Hg at a single office reading or ≥150/100 mm Hg with clinical evidence of target organ damage (left ventricular hypertrophy, hypertensive retinopathy or hypertensive nephropathy).

Treatment initiation:

  • In adults with confirmed hypertension, initiate pharmacologic treatment to lower blood pressure at systolic blood pressure (SBP) ≥140 mm Hg OR diastolic blood pressure (DBP) ≥90 mm Hg.
  • In adults with atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), aged 75 years or older, or 10-year ASCVD risk greater than or equal to 10%, consider pharmacologic treatment at SBP ≥130 mm Hg and treat to a goal of SBP <130 mm Hg.

Treatment target:

  • Treat to a goal of SBP <140 mm Hg AND DBP <90 mm Hg.
  • Lower targets are reasonable based on clinical risk factors, clinical judgement and patients’ preferences.
  • DM alone does not qualify for goal SBP <130 mm Hg.

For corresponding SBP/DBP values, corresponding SBP/DBP values, initial pharmacotherapy, and follow up recommendations see the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus.

 

FIGURE 3: CLINICAL GUIDELINES: COMPREHENSIVE DIABETES CARE


Guideline source

USPSTF, American Diabetes Association (ADA) and Kaiser Permanente National Guideline Program (July 2023)

PHMI measure
Comprehensive Diabetes Care

Guideline language

Screening (USPSTF): Asymptomatic adults aged 35 to 70 years who have overweight or obesity.

Diagnosis (ADA):

  • Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least eight hours. 

OR

  • Two-hour postprandial glucose ≥200 mg/dL (11.1 mmol/L) during oral glucose tolerance test. The test should be performed as described by World Health Organization using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 

OR

  • A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program certified and standardized to the Diabetes Control and Complications Trial assay. 

OR

  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L)

For the full ADA guidelines, see Diabetes Care 2. Classification of Diabetes: Standards of Care in Diabetes - 2023

For glycemic control and treatment targets, and guidelines for self-monitoring, see the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus.

 

Many key activities in this guide include considerations for utilizing the intervention to improve equitable health outcomes and reduce the effects of racism, bias and discrimination. Key Activity 4: Use a Systematic Approach to Decrease Inequities Within the Population of Focus describes key action steps for how to make an intentional and explicit effort to identify inequities, understand root causes and reduce those inequities.

This guide also offers resources for going deeper into organizational and ecosystem-level work to advance equitable outcomes through strengthening a culture of equity. More information about this approach can be found in the PHMI Equity Framework and Approach and Key Activity 21: Strengthen a Culture of Equity.

Integrated behavioral health supports are important for adults as effective management of chronic conditions is likely to boost health outcomes and enhance patients' quality of life.

To learn more about strategies for behavioral health integration see Getting Started with Behavioral Health Integration and the PHMI Behavioral Health Guide Key Activity 2: Enhance the Culture of Integrated Behavioral Healthcare and Key Activity 3: Enhance Operational Integration of Behavioral Health.

One foundational change is to ensure that the care team includes behavioral health staff as core members of the team; this is covered in detail in the PHMI Care Teams and Workforce Guide.
We also offer the resource Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care includes recommended behavioral health screenings.

Throughout the key activities in this guide, we have incorporated considerations for providing trauma-informed care and have included a resource for Trauma-Informed Population Health Management. For additional information, please see the PHMI People with Behavioral Health Conditions Guide. The Agency for Healthcare Research and Quality (AHRQ) also provides resources on integrating health equity and behavioral health.

The Agency for Healthcare Research and Quality (AHRQ) recommends that in order to advance health equity, practices and health systems must consider and address health-related social needs that impact their patients.[1]

For many key activities in this guide, we have highlighted considerations related to social needs at an individual or population level, such as expanding clinic hours and coordinating care. Key Activity 14: Use Social Needs Screening to Inform Patient Treatment Plans assists to develop a process to screen for social needs, which can help practices better understand and support patient- and population-level needs. Practices can help patients make connections to resources in the community to address issues such as nutrition and legal and health education needs. For Medi-Cal patients and families with high levels of social need, such as those experiencing homelessness, referrals to Enhanced Care Management (ECM) and Community Supports programs are available; see Key Activity 18: Provide Care Management for more.

To go deeper in this area, practices can further develop their referral relationships and pathways (Key Activity 19: Continue to Develop Referral Relationships and Pathways Networks) for common social needs and strengthen community partnerships (Key Activity 17: Strengthen Community Partnerships) to build upon the strengths, infrastructure, and resources available in the community. More information about this dual patient- and population-level approach is available in the PHMI Social Health Framework and Approach.

Our theory of change is that if practices implement the activities contained in this guide, it will lead to improved health and well-being outcomes among patients with chronic conditions served by these practices. See Appendix B: Theory of Change for a suggested driver diagram.

Endnotes

  1. New Federal Resources for factoring social determinants of health into clinical practice [Internet]. Agency for Healthcare Research and Quality (AHRQ); 2023 [cited 2023 Dec 1]. Available from: https://integrationacademy.ahrq.gov/news-and-events/news/new-federal-resources-factoring-social-determinants-health-clinical-practice