Written by: Center for Care Innovations

The Population Health Learning Network (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 strategies. Twenty five health care organizations are implementing a broad range of changes to maximize the health and wellbeing of their patient populations.

To inspire and encourage this work, we took PHLN teams on “site visits” to exemplar organizations around the country. These visits gave our participants the ability to hear directly from innovators and see what it really means to work differently.

To bring the spirit of this type of learning to those who aren’t able to travel, we asked three teams to create “site visit” videos that tell the story  of their own PHLN work. Chapa-De Indian Health, Santa Barbara Neighborhood Clinics and Tri-City Health Center’s work highlight different aspects of population health management.

Take a look below:

Chapa-De Indian Health 

Chapa-De Indian Health introduced the “advanced access” method of scheduling, in which most patients can book an appointment on the day they call, to reduce wait times for appointments and improve continuity of care. Listen to staff testimonials as to how this change has improved care for their patients and for the morale of staff.


Santa Barbara Neighborhood Clinics 

Santa Barbara Neighborhood Clinics recruited and integrated registered nurses as panel managers. They work closely with a medical assistant and focus on a specific population of patients, like those with diabetes, to improve the patient’s care and ensure that quality care measures are met. Learn about their role working in a call center, where they are conducting care management and panel management.


Tri-City Health Center 

Tri-City Health Center implemented the PRAPARE tool to identify social needs impacting patients’ health  in their diabetes group management classes. Learn about the workflow for this process and how these group classes influenced patients.