California is embarking on a fundamental shift in how it pays for healthcare. For California’s health centers, this pivot from volume driven payments to capitation payments means both significant challenges and important opportunities to provide more effective and efficient care.
To better prepare CA’s Federally Qualified Health Centers (FQHCs) for this transformation, the California Primary Care Association (CPCA) and the California Health Care Safety Net Institute (SNI) developed the Capitation Payment Preparedness Program—also known as CP3. The Center for Care Innovations (CCI) is providing key support, taking the lead in developing and implementing the program’s Population Health Management Technical Assistance Program.
CP3 is initially focused on a limited number of demonstration participants, but will eventually support all FQHC transition efforts across the state. CP3 will provide technical assistance around three core competency areas: (1) Population Health Management, (2) Data Management, and (3) Financial Management. The primary aim of the Population Health Management effort is to transform care processes and systems to achieve high value, quality healthcare. This means achieving improved patient outcomes, offering exceptional patient experiences, and providing care at the lowest cost for a health center’s entire panel of patients. Patients should be able to access their care team through multiple means—including visits to the clinic, email, phone, and online portal interactions. Care teams will proactively assess and address the needs of their population of patients, and there will be increased flexibility to build a workforce to fit those patient and community needs, including the use of a spectrum of licensed and non-licensed staff to address bio-psycho-social needs. Many FQHCs have already started this transformation work by adopting the Patient-Centered Medical Home (PCMH) model. However, that work is constrained by the need to achieve a certain number of visits within the boundaries of Prospective Payment System (PPS) rules.
The Population Health Management Technical Assistance Program has two program options: the Comprehensive Track and the Low-Intensity Track. The Comprehensive Track was a fast-paced year-long program that ended on April 30 2017 and included a combination of webinars, onsite sessions, coaching, and site visits that focus on assisting organizations in making measurable, progress in the core competencies. The Low-Intensity Track runs from September 2016-September 2017 is available to any organization participating in the APM and focuses mostly on sharing best practices and training via webinars, with access to consultations with subject matter experts.
See the CPCA’s CP3 page for more information.
For more information about this program, click “See All Related Resources” to the left.
Comprehensive Track Participants
|CommuniCare Health Centers||Sacramento Valley|
|LifeLong Medical Care||East Bay|
|Monterey County Clinic Services||Monterey County|
|OLE Health||Sonoma County|
|Ravenswood Family Health Center||East Palo Alto|
|San Mateo Medical Center||San Mateo County|
|Tiburcio Vasquez Health Center||East Bay|
|Venice Family Clinic||Los Angeles|
|Vista Community Clinic||Northern San Diego|
Comprehensive Track Program Activities and Timeline
The Comprehensive Track program featured an array of learning opportunities focused on three training modules: team-based care, planned care, and population health management. Teams received monthly coaching support, regular “swap meets” (virtual learning sessions), access to site visits, and consultation hours with subject matter experts.
Application Timeline, Comprehensive Track
- March 2016: Access slides and recording from the informational webinar, as well as application guidance.
- April 1, 2016: Applications due
- April 22, 2016: Selections made
- May 26, 2016: Virtual Kickoff Meeting, Comprehensive Track. Access presentation slides and a recording of the meeting here.
These full-day sessions allowed organizations to learn from experts and peers, and receive training in the Population Health curriculum.
- July 21, 2016: In-person Learning Session #1 in Oakland, CA, focused on change management and team-based care. Access the slides and handouts.
- September 21, 2016: In-person Learning Session #2 in Oakland, CA, focused on team-based care and planned care. Access the agenda and slides.
- December 6, 2016: In-person Learning Session #3 in Berkeley, CA, focused on alternative visits. Access the agenda and handouts, as well as the overall slides, and slides from the three learning labs: patient portals, telephone visits, and shared medical appointments.
- March 2, 2017: In-person Learning Session #4 in Oakland, CA, focused on using data for population health management. Access the agenda and the slides.
Webinars are opportunities for organizations to learn from a mix of expert training and peer sharing on topics identified throughout the program. All Comprehensive Track participants have access to the webinars listed below in the Low-Intensity Track.
CP3 Comprehensive Track participant organizations had the opportunity to attend one of three site visits to a health center demonstrating best practices in the three training modules covered in the program. Site visits occurred in October and November 2016, and locations included:
- West County Health Centers (Sonoma County, CA)
- Petaluma Health Center (Sonoma County, CA)
- Clinica Family Health (near Boulder, CO)
“Swap meets” were virtual learning sessions where CP3 Comprehensive Track participants could exchange ideas and share what they have been working on at their organizations in between in-person learning sessions.
- Thursday, June 30, 2016: “Swap Meet #1”: Journey Mapping the Team-based Care Experience. Access recordings and slides here.
- Tuesday, August 30, 2016: Swap Meet #2”: Communicating & Messaging around APM. Access recordings and slides here.
- Thursday, November 3 from 3-4pm: “Swap Meet #3”: Insights and Next Steps from Petaluma & West County Site Visits. Access recordings and slides here.
Each organization involved in the CP3 Comprehensive Track was assigned a coach. Coaches worked closely with project teams to start adapting changes for use in their own organization, testing changes, tracking data on changes, and capturing lessons learned. Each organization had up to 6 coaching hours available per month.
Faculty Office Hours
Virtual office hours via phone or a web-based service were set up following each on-site session to give participants the opportunity to dive deeper and ask questions of select faculty members. Each organization involved in the CP3 Comprehensive Track could initiate up to 10 hours of individual faculty office hours throughout the duration of the program.
End of Phase 1 Population Health Comprehensive Track Program: April 2017
Low-Intensity Track Program Activities and Timeline
The Low-Intensity Track runs from September 2016-September 2017 and is available to any organization participating in the APM. This track is focused on sharing best practices and training via webinars and in-person workshops, with access to optional site visits (by application).
Application Timeline, Low-Intensity Track
- September 2016: Access the slides and the webinar recording from the informational webinar here.
Webinars are opportunities for organizations to learn from a mix of expert training and peer sharing on topics identified throughout the program, including:
- October 7, 2016: Communicating & Making the Case for Change Across Your Organization. Click here to access the recording and slides.
- October 10, 2016: Empanelment Series 1.0, Part 1 “The Need to Belong.” Click here to access the recordings and slides.
- Monday, November 7, 2016: Empanelment Series 1.0, Part 2 “There’s No Room”. Click here to access the recordings and the slides.
- Thursday, November 17, 2016: Alternative Encounters, Part 1. Click here to access the recordings and the slides.
- Wednesday, November 30, 2016: Alternative Encounters, Part 2. Click here to access the recordings and the slides.
- Tuesday, February 7, 2017: Empanelment 2.0: Leveraging Empanelment to Increase Access. Click here to access the recordings and the slides.
- Tuesday, June 27, 2017: Moving Toward Value-Based Care: Lessons Learned from CCI’s CP3 Population Health Comprehensive Track Program. Click here to access the recordings and the slides.
- Wednesday, July 19, 2017: Building a Data-Driven Culture for Population Health. Click here to access the recordings and the slides.
- Thursday, July 27, 2017: Design-Thinking for Data Driven Culture. Click here to access the recordings and the slides.
- Thursday, August 10, 2017: Tableau in Action. Click here to access the recordings and the slides.
- Thursday, August 17, 2017: From Data to Action: Key Steps and Strategies for Using Data to Improve Care. Click here to access the recordings and the slides.
- Tuesday, August 29, 2017: Effective Communication Strategies for Strengthening Patient-Clinician Relationships. Click here to access the recordings and the slides.
CCI offered two, day-long in-person workshops in April 2017 with faculty from the Center for Excellence in Primary Care at UCSF. The workshops covered:
- April 10, 2017 Team-Based Care Workshop: This workshop was geared toward organizations that (1) can demonstrate an organizational commitment to transforming their care teams; and (2) are in the early stages of their developing care teams and have made some progress in defining clear roles and workflows for each care team member.
- April 11, 2017 Health Coaching Workshop: This workshop was geared toward organizations that (1) have already hired coaches with protected time built into their schedules to do both in-person health and telephonic health coaching; and (2) are familiar with the health coaching model and have some experience using it.
CCI will also host a day-long workshop focused on Patient Communication on September 7, 2017 in Oakland, CA. Organizations participating CCI’s CP3 Low-Intensity Track will be given priority to participate in the workshop.
CP3 Low-Intensity Track participant organizations had the opportunity to attend a site visits to a health center demonstrating best practices in population health management in October 2016. Sites visits will be offered again to Low-Intensity Track organizations in August and September 2017, including visits to the following organizations: