In May 2016, the Center for Care Innovations (CCI) launched a population health management program as part of a larger effort to prepare California’s Federally Qualified Health Centers (FQHCs) for planned shifts in reimbursement.

The larger effort, known as the Capitation Payment Preparedness Program – also called CP3 – was developed by the California Primary Care Association and the California Health Care Safety Net Institute. Within CP3, CCI designed a program to support FQHC participants with two goals:

  1. Transforming care processes and systems to achieve high-value, quality health care and
  2. Preparing CP3 sites for the care delivery changes needed to be successful in a capitated or value-based payment model.
CCI Program Goals and Activities


Value-based care directly connects how providers are paid for their services with the quality and cost efficiency with which that care is delivered. Value-based care initiatives support the transformation from a payment system based on the quantity of services delivered, to the effectiveness with which care is provided to individual patients and how the health of patient populations is managed.


In turn, population health management is driven by the use of data to identify and address the health care needs of a defined population. Population health management focuses on providing evidence-based preventive care, addressing gaps in care and effective management of chronic conditions through a focus on team-based care, patient engagement, and effective use of health information technology tools.


CCI’s population health program focused on four components designed to support clinics in moving from volume to value:

    1. Team-based care,
    2. Population health management,
    3. Planned care, and
    4. Transforming data into meaningful information to support population health management.

Program activities included four in-person learning sessions, intensive “learning labs” focused on key elements of value-based care, virtual swap meets to exchange resources, site visits, webinars, and coaching.

This toolkit consolidates the tools, resources and learnings of the population health program activities to support other health centers in their journey to value-based care.

Download the PDF or explore the resources below.