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.

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.

In partnership with the California Health Care Foundation (CHCF) and Blue Shield of California Foundation (BSCF), the Center for Care Innovations (CCI) launched the Population Heath Learning Network (PHLN). Up to 30 organizations were selected to participate in this two-year network focused on learning, sharing best practices, and taking action to advance population health.