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 Implementation Model

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.

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Children

Child Immunization Status

Well-Child Visits in First 30 Months of Life

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Pregnant People

Prenatal and Postpartum Care

Adult Preventative Care Landscape

Adults with Preventive Care Needs

Colorectal Cancer Screening

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Adults Living With Chronic Conditions

Controlling High Blood Pressure

Comprehensive Diabetes Care

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People with Behavioral Health Conditions

Depression Screening and Follow-Up for Adolescents and Adults

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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:

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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.

 

PHMI Timeline