Child Immunization Status (CIS 10)
Well Child Visits in first 30 months of life (first 15 months)
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.
Child Immunization Status (CIS 10)
Well Child Visits in first 30 months of life (first 15 months)
Colorectal Cancer Screening
Hemoglobin A1c Control for Patients With Diabetes (Poor Control >9%)
Controlling High Blood Pressure
Prenatal & Postpartum Care (Postpartum)
Depression Screening & Follow-Up for Adolescents and Adults
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 PHM Initiative, think through ideal future state experiences for patients and care team members, and brainstorm solution concepts to consider for detailed design of the PHM Initiative change package.
Two phases emerged from the co-design process with Community Health Centers
Community Health Centers will lay the groundwork to effectively implement PHM for a selected population.
Each Community Health Center will select a core PHM Initiative Population of Focus and apply the following core interventions, including, but not limited to:
The PHM Platform will provide additive capabilities by functioning with existing Community Health Center technologies to enable robust, interoperable technology solutions. The PHM Initiative Platform’s capabilities are designed to enable care delivery model interventions and strives to achieve:
Incorporate and harmonize data from multiple external sources to provide actionable analytics to better inform patient level, whole person care
Aggregate data across the state to inform and enhance data-sharing capabilities among Community Health Centers and across the Medi-Cal delivery system
Expedite implementation and improve performance related to CalAIM and APM 2.0 through data standardization and interoperability to drive holistic patient care together
The PHM Initiative is a five-year program to co-design population health management strategies to advance provider capabilities and address disparities.