Child Immunization Status (CIS 10)
Well Child Visits in first 30 months of life (first 15 months)
Our Program
Providing resources for innovative care at California’s Community Health Centers
We’re 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.
PHM Initiative Core 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.
Pediatric Prevention
Adult Prevention & Management
Colorectal Cancer Screening
Hemoglobin A1c Control for Patients With Diabetes (Poor Control >9%)
Controlling High Blood Pressure
Maternity Care
Prenatal & Postpartum Care (Postpartum)
Behavioral Health
Depression Screening & Follow-Up for Adolescents and Adults
Our Co-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 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.
Phases of PHM Initiative Implementation
Two phases emerged from the co-design process with Community Health Centers
Building the Foundation
Community Health Centers will lay the groundwork to effectively implement PHM for a selected population.
- Develop a business case for PHM Initiative 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
PHM Initiative Populations of Focus
Each Community Health Center will select a core PHM Initiative 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
Integrated PHM Platform
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:
Insights
Incorporate and harmonize data from multiple external sources to provide actionable analytics to better inform patient level, whole person care
Systemness
Aggregate data across the state to inform and enhance data-sharing capabilities among Community Health Centers and across the Medi-Cal delivery system
Acceleration
Expedite implementation and improve performance related to CalAIM and APM 2.0 through data standardization and interoperability to drive holistic patient care together
Program Timeline
The PHM Initiative is a five-year program to co-design population health management strategies to advance provider capabilities and address disparities.
