Population Health Management Capabilities Assessment Tool (PhmCAT)

What is the Population Health Management Capabilities Assessment Tool (PhmCAT)?

The PhmCAT is a multi-domain assessment that is used to understand current population health management capabilities of primary care practices or Community Health Centers. This self-administered tool can help organizations identify strengths and opportunities for improving population health management. It can also be used to assess changes over time if administered at multiple time points.


How was it developed?

The PhmCAT was developed by Kaiser Permanente’s Population Health Management Initiative (PHMI) team in consultation with a workgroup comprising representatives from the California Department of Health Care Services (DHCS), California Primary Care Association (CPCA), Partnership Health Plan, Alameda Health Consortium, and the University of Chicago. The tool assesses eight common domains across PHMI, Alternative Payment Methodology (APM), and Health Equity and Practice Transformation deemed critical for effective population health management:

• Leadership & culture
• Business case for PHM
• Technology & data infrastructure
• Empanelment & access
• Care teams
• Patient-centered, population-based care
• Behavioral health
• Social health

The PhmCAT includes 50 questions total across the eight domains, most from validated or frequently used assessment tools. Each question is rated on a 10-point scale - 1 being low/not in place, 10 being high/in place.

How is it completed?

The PhmCAT is designed to be completed by a multi-disciplinary team within a primary care practice or Community Health Center. The assessment asks about organizational systems and practices, as well as clinical practices, so the team must include diverse representation including people with clinical, operational, financial, data and patient-facing experience and expertise. If your organization is using the PhmCAT to guide improvement activities at a specific site, staff and clinicians from that site or practice should be involved in the team completing the assessment.

Each team member should complete the assessment individually, and then the team should come together to discuss responses and come to agreement on a consensus response for their practice on each question. This “consensus conversation” within the team is an important part of the process to learn from each other and reach a common understanding of current state. Results can be used by the team to identify opportunities and priorities for improvement. Many teams find an external coach or facilitator is helpful in guiding this consensus conversation.

What should you consider as you complete the assessment?

When answering each question, select the score that reflects where your practice is in its population health journey as honestly and accurately as possible. Each question has descriptions along the response scale to help explain what a given numerical score means. There is no advantage to overestimating or upcoding scores, and doing so may make it harder for real progress to be apparent if the assessment is repeated in the future.

For items you don’t have enough information to answer individually, please use the “don’t know” response option. When the group comes together to discuss, the team should be able to determine an accurate rating for each item.