Population Health Management Resources

We’ll be continuously offering resources including guides, tools, and best practices around expanding specific population health management capabilities. These resources support anyone interested in population health improvement for providers and practices in the Medi-Cal delivery system.

Assessment

PHM Capabilities Assessment

PhmCAT is a multi-domain assessment that is used to understand current population health management capabilities of primary care practices or community health centers. This self-administered tool can help organizations identify strengths and opportunities for improving population health management.

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Building the Foundation

Introduction to the Guides

Whether you are a community health center (CHC) or another type of primary care practice, this publicly available series of tools and materials is designed to support you in building a foundation for strong population-based care. In this document you will learn about the Population Health Management Initiative (PHMI) and its many partners across the state of California who are working together to support improved care for Medi-Cal members.

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Data Quality and Reporting Guide

This guide will help your practice enhance capacity to report and monitor PHMI/HEDIS quality measures for populations of focus using standardized measurement specifications and a data mapping assessment, and use it to improve quality of care.

Here you’ll find the executive summary, full guide and eight associated tools and resources.

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Empanelment Guide

This guide will help your practice select and implement a methodology to create patient panels and develop continuity reports.

Here you’ll find the executive summary, full guide and eleven associated tools and resources.

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Care Teams and Workforce Guide

This guide will help your practice assess current care team roles and functions, identify gaps, and develop and execute a workforce plan.

Here you’ll find the executive summary, full guide and six associated tools and resources.

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Business Case Guide

This guide will help your practice to develop your financial model for population health management sustainability. This tool is currently designed for community health centers and how they are paid, but can be adapted by other practices.

Here you’ll find the executive summary, full guide and two associated tools and resources.

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Clinical Guidelines

Clinical Practice Guidelines for Key Medi-Cal Populations of Focus

This set of clinical guideline recommendations were chosen based by the populations of focus and clinical conditions that are the focus of PHMI. PHMI plans to support community health centers in using these clinical guidelines to guide care.

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Populations of Focus

Resources Coming Soon