Outreach Protocol Affinity Group Sessions (March-May 2025)
PHMI has designated a foundational competency across four Populations of Focus: “Develop an outreach protocol for all attributed patients including those who have not been seen.” We have learned from coaches and SMEs how hard this can be hard to do. Barriers include incomplete health plan data, inability to contact by phone or address due to un-homed status or incorrect phone data, variable MCP assignment methodologies as well internal challenges such as lack of medical record information. We invited centers, coaches and Population of Focus subject matter experts for a three-month deep dive to collectively develop approaches and strategies to test, study and act. Our goal, that your center will be able to meet the validation criteria for this foundational competency as a result of participating in this affinity group.
Learning Objectives
- Advance your team’s competency in implementing an outreach protocol to reach the foundational competency.
- Exchange insights and experiences with peers on outreach strategies.
- Articulate the steps needed to create an effective outreach protocol.
- Optimize the functionality of our CHC's PHM Tool to obtain and manage input data from multiple sources.
- Gain insights into promising outreach strategies from the field to inform your work.
- Learn how to use outreach strategies to address health inequities.
- Explore small, actionable change ideas that can be tested to build and document a robust outreach protocol
This three-part affinity group series supports health centers in developing documented outreach protocols for attributed patients due for care. Materials include slides and recordings focused on patient attribution, data quality, outreach workflows, population health management tool and technology use, equity, and measurement. The sessions feature health center examples and peer discussion on common implementation challenges, including poor data, limited staffing, process documentation, campaign planning, and tracking progress over time.
Session 1: March 18, 2025
This session introduces the outreach protocol foundational competency and sets context around patient attribution, assignment, and outreach planning. It includes an Eisner Health Center example, a people/process/technology outreach framework, and a Miro activity to help health centers identify outreach pain points and opportunities.
Session 2: April 15, 2025
This session builds on identified outreach challenges by focusing on front-end capabilities, bad data, process documentation, and outreach campaign planning. Examples from Venice Family Clinic and Long Valley Health Center show how health centers are using data, technology, and patient segmentation to prioritize outreach and refine outreach protocols.
Session 3: May 20, 2025
This session synthesizes lessons from the series and focuses on outcome measurement for Population of Focus outreach strategies. It includes a UMMA Community Clinic bright spot on planning outreach campaigns, tailoring outreach approaches, tracking screening progress, and using measurement to guide continued improvement.