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.

PHMI Implementation Model

PHMI 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.

Doctor Child@2x Aspect Ratio 391 185

Pediatric Prevention

Child Immunization Status (CIS 10)

Well Child Visits in first 30 months of life (first 15 months)

Istock 1350731603 2 Aspect Ratio 391 185

Adult Prevention & Management

Colorectal Cancer Screening

Hemoglobin A1c Control for Patients With Diabetes (Poor Control >9%)

Controlling High Blood Pressure

Maternal Health Aspect Ratio 391 185

Maternity Care

Prenatal & Postpartum Care (Postpartum)

Adult Preventative Care Aspect Ratio 391 185

Behavioral Health

Depression Screening & Follow-Up for Adolescents and Adults

Patient Clipboard@2x Aspect Ratio 507 467

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 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.

Phases of PHMI 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 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

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

Integrated PHMI Platform

The PHMI Platform will provide additive capabilities by functioning with existing Community Health Center technologies to enable robust, interoperable technology solutions. The PHMI Platform’s capabilities are designed to enable care delivery model interventions and strives to achieve:

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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

Program Timeline

The Population Health Management Initiative is a five-year program to co-design population health management strategies to advance provider capabilities and address disparities.


Phmi Timeline@2x