Historically, most primary care practices, including health centers, have provided episodic care to individuals who booked appointments or needed emergency care. Practices optimized their workflows and staffing models to address the medical needs of these “active” patients during face-to-face encounters in clinical settings. Over the past two decades, a sea change has swept through health care, forcing organizations to rethink—and reorganize—how they care for their patients and their communities.

Today, primary care organizations aim to proactively manage the health of a defined population of patients that is assigned to them; in California, this is established most often by a Medi-Cal Managed Care Plan. As such, there is a need to use data to identify, segment, and appropriately respond to medical, behavioral, and social needs through effective care interventions. And recognizing that social determinants (health-related behaviors, socioeconomic factors, and environmental factors) account for up to 80 percent of health outcomes, there is also a need to broaden the population health management lens to include understanding the social, political, and cultural context in which patients and their families live and to focus on providing whole-person care.

Such a change requires developing new skills in patient outreach and engagement, adding new roles to care teams, building community partnerships to address social needs, and connecting with patients over email, phone, telehealth and other methods in addition to the traditional office visit.

CCI has more than 17 years of experience grantmaking, designing and implementing high-quality, high-value programs and networks, as well as offering robust technical assistance to safety net organizations and health care systems. Previously, CCI led the Capitation Payment Preparedness Program (CP3) Population Health Program, which prepared organizations for the care delivery changes needed to succeed in a capitated, or value-based payment, environment. Participating organizations made changes such as increasing provider-to-medical-assistant ratios by 50 percent; adding new roles like navigators, panel managers, pharmacists, and behavioral health clinicians to care teams; implementing robust data reports for planned care and outreach; and incorporating alternative encounters like telephone and group visits.

Despite setbacks to California’s Alternative Payment Methodology Pilot (APM), market trends indicate value-based payment is on the immediate horizon. Organizations must to prepare for the changes needed to succeed in a value-based environment. Building on our past CP3 Population Health Program, CCI is launching a new network focused on sharing best practices, innovating new care solutions, and advancing the spread of vetted changes that propel organizations towards value-based care and payment models.

Launching a New Network

In partnership with the California Health Care Foundation (CHCF) and Blue Shield of California Foundation (BSCF), the Center for Care Innovations (CCI) is launching a Population Heath Learning Network (PHLN). The PHLN aims to improve the health and wellbeing of more than 750,000 Californians by bringing together safety net primary care organizations to strengthen and advance their population health management strategies.

There is ample evidence supporting the implementation of population health management approaches in primary care. A strong focus on population health management allows organizations to:

  • Target the right resources to the patients who need it most.
  • Provide better access to care through alternative encounters, such as phone visits.
  • Improve the patient’s experience of care.
  • Achieve better health outcomes by closing gaps in care.
  • Boost workplace satisfaction by optimizing team-based care and ensuring all staff can work to the top of their skill and license.
  • Reduce emergency department utilization and hospital readmissions through coordinated care.
  • Stabilize or reduce health care costs.

Up to 30 organizations in California will be selected to participate in this two-year network focused on learning, sharing best practices, and taking action to advance population health.

Over the two-years in the network, organizations will commit to attending three in-person convenings and also select from a robust array of technical assistance and support depending on their needs in managing population health. This can include consultations from experts, capability-building trainings and webinars, site visits to peers and exemplars, and 1:1 customized coaching on core content areas listed below. Travel grants between $4,000 and $8,000 will also be provided to all participants to offset costs to attend in-person convenings and site visits.

In year two, participating organizations can apply for grants of up to $30,000 to support deeper implementation of one or more population health management strategies tested in year one. Grants will be made through a competitive application process.

Network Structure & Core Content

Organizations interested in participating in the PHLN must be able to demonstrate an aptitude and commitment for advancing their population health management strategies and tactics. Participants will be expected to enter the network with the following core capabilities in place:

  • A team-based model of care implemented in most sites;
  • Empanelment processes with most patients empaneled to a clinician or care team;
  • Data infrastructure that includes processes around data governance, validation, and data reporting to facilitate clinical decision making at the point of care; and
  • A strong quality improvement culture where changes are tested, measured, and evaluated for implementation or spread.

The network provides an opportunity to enhance existing capabilities and to develop new capabilities (e.g., more sophisticated data reporting skills) through peer sharing and learning from exemplars within and outside of California.

Organizations must be committed to networking with peers and will be expected to proactively share strategies, challenges, and best practices with one another. While customized technical assistance and coaching will be available, the emphasis of this network will be sharing and spreading ideas and best practices among peers — not didactic teaching from experts. Lastly, organizations should enter the network with a clear commitment to spread what they learn internally (from one site to another) and to participate in project-end activities intended to share lessons beyond the network.

Required activities are three, 1.5 daylong in-person convenings to enable peer sharing and learning from healthcare and non-healthcare faculty. Participants will be able to access supplemental support through webinars, site visits, expert consultants, and coaching based on their specific needs, capabilities, and goals. Learning, sharing, and technical assistance will be focused on the PHLN’s core content:

  1. Leadership and Change Management: Understanding adaptive and technical challenges. Communicating around large change initiatives. Clarifying leadership roles and how leaders work together to provide integrated care.
  2. Team-Based Care 2.0: Delivering patient-centered care through redefining and experimenting with team roles and alternative visits, creating access and managing population health in a value-based care and payment environment. Standardizing care teams across organization.
  3. Planned Care and In-Reach: Gauging patients’ needs and delivering timely services and support, with an emphasis on leveraging technology, data tools for clinical decision making, and patient engagement strategies.
  4. Proactive Outreach: Displaying and engaging the care team in using data, as well as the data systems for analytics and reporting. Partnering with health plans for data exchange. Considering risk stratification to enable effective outreach.
  5. Behavioral Health Integration: Bringing behavioral health and somatic medicine together at the care team level to better detect illness, improve overall health outcomes, create a better patient experience, and reduce suffering.
  6. Care Management for Complex Patients: Identifying high-risk patients. Defining interventions for patients based on strata. Integrating behavioral health. Building community partnerships. Managing hospital transitions.
  7. Social Needs: Screening and prioritizing nonmedical needs. Building internal systems, referral processes, and effective partnerships with community organizations to respond to identified needs.

Additional capability-building workshops and webinars will be offered in year one. Participants will be able to opt out of these workshops and webinars if they participated in the CP3 Population Health Comprehensive Track Program, a comparable CCI program, and/or demonstrate high aptitude when applying to the network. Topics include:

  • Quality Improvement and Human-Centered Design: Setting aims and measures. Using PDSA cycles. Identifying changes through innovation and user-centered design approaches. Change management.
  • Leveraging Data as an Asset: Data governance, stewardship, and using data to drive clinical and operational decisions.
  • Team-Based Care with Behavioral Health Integration 1.0: Understanding the spectrum of behavioral health integration, components of integrated care, and populations served. Building the team, including roles and relationships, practice space, communication, screening, warm handoff, and treatment plan.
  • Access and Panel Management: Using data regularly to manage supply and demand, panel size, risk adjusting panels, access to care, using alternative visits.

In year two, we’ll offer grants of up to $30,000 to support specific project ideas that focus on deeper implementation of one or more population health strategies. Example project ideas could include experimenting with health plans to offer coordinated care transition plans, developing complex care management programs for high risk patients, and building relationships with community partners to facilitate streamlined referrals to address social needs. Organizations will be eligible to apply for and receive more than one grant award.
In early 2019, organizations will submit a specific project — including goals, draft metrics, and planned activities — to be considered for the grant. Each project will be evaluated and participants should expect to provide additional data to support this evaluation. Qualifying organizations will be those that successfully participated in year one of the PHLN by attending convenings, participating in evaluation activities, and facilitating a peer connection through a site visit or webinar.

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