Child Immunization Status
Well-Child Visits in First 30 Months of Life
Our Program
Providing resources for innovative care at California’s Community Health Centers
The Population Health Management Initiative (PHMI) is working directly with a cohort of Community Health Centers to implement the latest population health management infrastructure. We are collaborating to improve the quality of care and address disparities for all patients and families served by California Community Health Centers.
PHMI Populations of Focus and Quality Measures
We worked together to identify key populations of focus and related measures of success. These measures are directly aligned with APM 2.0 to help organizations align payment structure with equity-based population health. Each Community Health Center has selected an area of focus and metrics that are most meaningful for the care they deliver and the people they serve.
Children
Pregnant People
Prenatal and Postpartum Care
Adults with Preventive Care Needs
Colorectal Cancer Screening
Adults Living With Chronic Conditions
Controlling High Blood Pressure
Comprehensive Diabetes Care
People with Behavioral Health Conditions
Depression Screening and Follow-Up for Adolescents and Adults
Our Collaborative Design Process
Leaders from Community Health Centers, Regional Associations of California, California Primary Care Association, Department of Health Care Services, and Kaiser Permanente came together for interactive sessions to collaboratively align on the Population Health Management Initiative, think through ideal future state experiences for patients and care team members, and brainstorm solution concepts to consider for detailed design of the PHMI change package.
PHMI Implementation
Based on the collaborative design process with Community Health Centers, two phases of implementation and a set of implementation supports emerged:
Phase 1: Building the Foundation
Community Health Centers will lay the groundwork to effectively implement population health management (PHM) for a selected population.
- Develop a business case for PHMI Sustainability
- Enhance capacity to report and monitor key quality measures
- Implement empanelment methodology and develop continuity reports
- Build high-functioning care teams to provide PHM services
Phase 2: PHMI Populations of Focus
Each Community Health Center will select a core PHMI Population of Focus and apply the following core interventions, including, but not limited to:
- Operationalization of clinical guidelines
- Creating chronic condition specific registries
- Outreach and engagement for proactive population management
- Pre-visit planning to reduce care gaps
- Care coordination to ensure effective transition planning
- Behavioral health integration to treat the whole person
- Social health screening and assessment to identify risk factors
Implementation Supports
Kaiser Permanente is investing in Community Health Centers to ensure their success in PHMI implementation by offering:
- Technical assistance from practice coaches, HIT coaches, and subject matter experts
- Implementation guides with resources and tools for each phase
- Peer learning opportunities through webinars, affinity groups, e-learning, and more
- Grant funding for program and technology implementation support
- PHMI Platform providing data integration and actionable insights
Integrated PHMI Platform
The PHMI Platform is a technology solution that functions with existing Community Health Center (CHC) technologies, enabling them to improve care quality and equitable health outcomes. It supports CHC and PHMI goals by:
Aggregating data from multiple sources to provide actionable analytics and better inform whole-person care
Strengthening and automating care management, physician engagement, patient outreach, and reporting workflows
Preparing CHCs for participation in CalAIM, APM 2.0, and value-based care
Building a foundation for statewide data aggregation, with the goal of enhancing data-sharing capabilities across the Medi-Cal delivery system
Program Timeline
The Population Health Management Initiative is a five-year program to collaboratively design population health management strategies to advance provider capabilities and address disparities.
