Year 2 Grant Opportunity

Nearly a year ago, the Center for Care Innovations (CCI), in partnership with the California Health Care Foundation (CHCF) and the Blue Shield of California Foundation (BSCF), launched the Population Health Learning Network (PHLN). The PHLN aims to improve the health and wellbeing of more than 1.2 million Californians by bringing together safety net primary care organizations to strengthen and advance their population health management capabilities. Twenty-five safety net health care organizations were accepted to participate in this two-year network focused on learning, sharing best practices, and taking action to advance population health.

As we enter the second year of the network, CCI is offering up to 26 grants of $30,000 each to support project proposals that focus on implementation or spread of one or more population health strategies. This opportunity is not competitive. Thanks to additional support from Dignity Health, we expect to issue awards to all participants who meet established criteria. Participants may submit proposals for up to two separate grants; however, secondary awards will only be made if there are sufficient funds remaining after all participants who meet established criteria receive their initial awards.

Key Dates

  • Application Launch: Thursday, January 17, 2019
  • Application Deadline: Friday, February 8, 2019
  • Grants Announced: By Friday, March 1, 2019
  • Kickoff Webinar: Tuesday, March 19, 2019
  • End of Grant: Friday, February 28, 2020


Year 2 Implementation Grant Opportunity

In year two, CCI is offering up to 26 grants of $30,000 each to support project proposals that focus on implementation or spread of one or more population health strategies. Proposed projects should:

  • Build on, strengthen, deepen, or spread ideas that advance your organization’s population health work;
  • Be focused on implementing an idea or strategy tested (partially or fully) in year one of the PHLN.

This is not a planning grant but one that is focused on action, implementation, and advancing work in an area in which you already have experience. Proposed projects should be aligned with your organization’s current population health strategy and successfully demonstrate how they will help advance your organization’s overall population health capabilities. This is also not an innovation grant opportunity; although the proposed project you select does not need to be evidence-based, it should be a feasible and impactful change that builds on work already underway and connected to content shared in the PHLN.

This opportunity is not competitive. We expect to issue awards to all participants who meet established criteria. Participants may submit proposals for up to two separate grants; however, secondary awards will only be made if there are sufficient funds remaining after all participants who meet established criteria receive their initial awards.

Projects should be focused on one or more of the PHLN’s core content areas:

  1. 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 the organization.
  2. Planned Care and In-Reach: Gauging patients’ needs and delivering timely services and support during visits, with an emphasis on leveraging technology, data tools for clinical decision making, and patient engagement strategies.
  3. Proactive Outreach: Identifying and closing gaps in care between visits and/or to assigned patients that have not established care. Developing strong data tools 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, and working on strategies for engaging patients and assigned members.
  4. Behavioral Health Integration: Bringing behavioral and physical health together at the care team level to better detect illness, improve overall health outcomes, create a better patient experience, and reduce suffering. Building and implementing registries, developing standard screening and data collection tools, integrating and implementing a model for behavioral health integration (i.e., Collaborative Care Model, IMPACT, etc).
  5. Care Management for Complex Patients: Identifying high-risk patients with data tools that stratify patients into risk levels. Defining interventions for patients based on strata. Integrating behavioral health and other modalities to address whole person care. Building community partnerships. Managing hospital transitions.
  6. Social Needs: Screening and prioritizing nonmedical needs. Building internal systems, referral processes, and effective partnerships with community organizations to respond to identified needs.
  1. Data Governance & Analytics: Data governance, stewardship, and analytic tools. Data visualization and data transparency.

Proposed projects should align with the goals you established in the first year of the program and activities you have been working on, and be appropriate in scope, meaning something you can accomplish within 12 months. Example projects could include:

  • Adding a new role to your organization’s core care team.
  • Developing and implementing a suite of new population health-related data reports to support in-reach and/or outreach processes across your organization.
  • Developing and implementing a registry for behavioral health with care team roles and workflows.
  • Implementing a new or revamped alternative visit such as a group visit, flip visit, or telephone visit.
  • Implementing a social needs screening protocol, tool, or workflow.
  • Revising and implementing a new algorithm for stratifying patients who might benefit from complex care management.


Who Is Eligible?

Qualifying organizations have successfully participated throughout the first year of the PHLN, by:

  1. Having core team attendance at the May 2018 and January 2019 convenings;
  2. Engaging in evaluation activities, including the baseline assessment and quarterly progress reports; and
  3. Participating in peer connections with other PHLN organizations by presenting on a PHLN webinar or at a convening; exchanging information through a phone call, email, and/or meeting with other PHLN teams in-person when requested; or sharing resources or answering other teams’ questions posted on the PHLN forum.

What Makes a Strong Proposal

Proposals will be awarded depending on alignment with the following criteria:

  • Connection of the proposed project to at least one core content areas covered in the PHLN;
  • Connection of proposed project to your overall aims developed in year one;
  • Scope of the project and feasibility given the grant resources and 12-month timeline;
  • Plan for tracking incremental progress and impact of the project on patients, organization operations, efficiency, and/or costs; and
  • Ability of the proposed project to be sustained beyond the grant timeline.
  • Demonstration that the proposed project will help advance or accelerate your organizations’ population health capabilities.
  • A designated project lead who has actively participated in PHLN-related activities.

Our Expectations

Organizations submitting grants will be expected to commit to the following:

  1. Continue Participation in Network Activities & Dedication to Sharing: Team members are expected to continue to fully participate in network activities, and share lessons learned by presenting examples of project successes and challenges at learning sessions and in other opportunities. Specifically, grantees will be asked to present their initial project findings during the final PHLN convening on December 5, 2019 and the final PHLN webinar by the end of May 2020.
  2. Evaluation and Metrics Collection & Progress Reporting: Teams will be asked to define a set of measures and with the help of CCI’s program evaluator, create a measurement work plan at the beginning of your project to track relevant metrics and milestones around your proposal’s impact on your organization and patients. CCI and the program evaluator will monitor and support your progress using these measures throughout the duration of the grant award period. Teams will be asked to submit metrics quarterly (April 30, 2019; July 30, 2019; October 30, 2019; January 30, 2020; and April 30, 2020).

Our evaluation partners at JSI will be hosting an optional webinar on Thursday, January 24 from 12-1pm to share considerations for selecting measures for the year two grant opportunity. Register here.

In addition to metrics collection and progress reporting, teams will be expected to continue to participate in the full PHLN evaluation activities through the summer of 2020.

  1. Affinity Groups & Forum Usage: Teams will be matched in triad affinity groups based on the areas in which you are doing work. In year two, the expectation will be for teams to check in at least quarterly (preferably through the PHLN online forum) to share progress and help overcome challenges experienced.

Questions & How to Apply

All questions should be submitted through the PHLN forum at In addition, CCI will be hosting two, 30-minute Q&A sessions for any teams that have questions about the scope of the project proposals. The sessions are scheduled for:

  1. Friday, January 25 at 12pm:
  2. Thursday, January 31 at 12pm:

Your application must be submitted online by 5:00 pm on February 8, 2019.

Applications should include the following:

  1. Application Submission Form
  2. Response to Application Questions
  3. Budget (use template provided)

Application Questions 

Please limit responses to a maximum of six pages, using at least 11-point font and 1-inch margins.

  1. Problem: What problem are you trying to understand and solve? Why is this a problem for your organization?
  2. Project Description: Describe the project you are proposing to work on, including:
    • Goal(s): What are you hoping to accomplish?
    • Key Activities: How will you accomplish this project? What are the key steps you will take?
    • Measures: What core process and outcome measures would you use to track your progress? Measures should evaluate progress towards your goals. These could include process measures that relate to the changes you are trying out or outcome measures that relate to improvements in clinical outcomes, patient or care team experience, improved operations, or cost efficiency. In proposing your measures, think about where you would expect to see movement within the timeframe of the grant. Also consider what data you will need and how you will collect it.
    • Impact: If successful, what short-term and long-term impacts would this project have on your organization?
  3. Current Experience: What is your current experience in this area? Describe any activities/efforts in this area during Year 1 of the PHLN, including what you have tested thus far and what you have learned?
  4. Organizational Alignment & Sustainability: How does your proposed project advance your organization’s population health management capabilities? How will your organization plan to sustain your efforts beyond the grant period?
  5. PHLN Connection: How will your learnings, experiences, and connections in the first year of the network contribute to your success with this proposed project? What do you need from the PHLN to be successful in year two?
  6. Closing Thoughts: Please include any other information here that you would like us to know in considering your proposal.

Download RFA

Apply Here

Contact Us

For any other questions, please contact:

Diana Nguyen
Program Coordinator
[email protected]