Population Health Management (PHM) Initiative
The PHM Initiative is a cohesive plan of action for addressing the needs of all members across the continuum of care. Under CalAIM, managed care plans must implement a whole-system, person-centered strategy that provides population health services, care management and care transitions across delivery systems and settings. Prior to CalAIM, HPSM had several key PHM elements in place through our Medi-Cal program as part of California Department of Health Care Services (DHCS) and internal programs.
Focusing on population health:
- Improves care for Medi-Cal members by putting people in the center, with a focus on prevention, wellness and care coordination services for all members through the Basic Population Health Management Program
- Reduces health disparities through improved community partnerships, member engagement and a broader focus on addressing unmet health and health-related social needs
- Makes important advances in quality by establishing targets and benchmarks to measure quality, with a focus on preventive care and wellness
Population Health Management at HPSM
HPSM’s Population Health team uses a data-driven approach to improve programs and services for our membership. We accomplish this by conducting an annual population needs assessment (PNA) to review population demographics, health care use, social determinants of health and member experience data. PHM workgroups use data to make improvements in key focus areas including perinatal health, child and youth health, chronic condition management and adult preventive health. For more information, email [email protected].
Partnering for a healthier community
We partner closely with San Mateo County Health on their Community Health Assessment (CHA) and Community Health Improvement Process (CHIP). The CHA assesses County residents’ health needs and quality of life. The CHIP is a collaborative plan that describes how San Mateo County Health and community partners work towards a shared vision to improve health and advance equity in San Mateo County.
HPSM meaningfully participates in the San Mateo County CHA/CHIP process by:
- Sharing data on populations of focus
- Gathering input from our provider network and Community Advisory Committee
- Participating in the CHIP Steering Committee and workgroups (including Access to Care, Mental Health and Social Determinants of Health)
- Regularly presenting findings from our network analyses and PNA to the CHA/CHIP workgroups to inform improvement activities
- Committing significant funding to support CHA/CHIP implementation