CalAIM Population Health Management Initiative

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In 2023, the Department of Health Care Services (DHCS) will launch Population Health Management (PHM), which is a cornerstone of CalAIM.

PHM will establish a cohesive, statewide approach that ensures Medi-Cal members have access to a comprehensive program that leads to longer, healthier and happier lives, improved health outcomes, and health equity. Several of the key elements of PHM were already in place in the Medi-Cal program prior to CalAIM through both DHCS policies and Medi-Cal managed care plans' procedures and programs. Under PHM, plans and their networks and partners are responsive to individual member needs within the communities they serve, while also working within a common framework and set of expectations.

PHM will establish a comprehensive, accountable plan of action for addressing member needs and preferences across the continuum of care, which requires plans to:

Build trust and meaningfully engage with members;
Gather, share, and assess timely and accurate data on member preferences and needs to identify efficient and effective opportunities for intervention through data-driven risk stratification processes, predictive analytics, identification of gaps in care, and standardized assessment processes;
Focus on upstream approaches that link to public health and social services and supports members staying healthy through wellness and prevention services;
Provide care management, care coordination and care transitions across delivery systems, settings, and life circumstances; and
Identify and mitigate social drivers of health to reduce disparities.

Beginning in 2023, all plans will be required to meet the National Committee for Quality Assurance's standards for Population Health Management as well as additional DHCS statewide PHM standards that are aligned with the requirements listed above.

CalAIM's PHM program is designed to proactively assess and address the care needs of beneficiaries with tailored interventions. By 2023, plans are expected to be responsible for the care of more than 90 percent of Medi-Cal beneficiaries. Establishing a unified, statewide approach to PHM ensures that all members — children, their parents, pregnant persons, elderly and other adults, and people with disabilities — have access to a whole-system, person-centered program that leads to longer, healthier lives, improved clinical outcomes and a reduction in disparities. The launch of PHM is part of a broader arc of change to improve health outcomes across the state that began with CalAIM, under which Enhanced Care Management (ECM) and Community Supports are implemented. This change is also further articulated in DHCS' Comprehensive Quality Strategy (CQS), as well as the Medi-Cal's Strategy to Support Health and Opportunity for Children and Families.

While the PHM program rolls out, DHCS is building a statewide PHM Service designed to collect and integrate disparate information to support DHCS' vision for PHM. Most notably, the PHM Service will:

Provide plans, providers, counties, Medi-Cal members and other authorized users access to more timely, accurate, and comprehensive data on members' health history and needs, to help improve care, and avoid duplicative processes.
Support risk stratification and segmentation and risk tiering functions.
Promote trusting relationships between members and their care team by making it easier for members to update their information and providing members with access to health education, their rights and applicable benefits, and information on how their data are being used, among other features.
Improve DHCS' ability to understand population health trends and support oversight.

The PHM Service will be deployed in Q3 2023, and capabilities will be incrementally phased in. DHCS has been working with and will continue to work with stakeholders to identify the priorities, and capabilities that the PHM Service will support.

Download the factsheet about the CalAIM Population Health Management initiative.

Important Updates

Updated PHM Policy Guide

On January 22nd, 2024, DHCS released the updated PHM Policy Guide that provides updated operational guidance for the modified Population Needs Assessment (PNA) and makes minor clarifying edits (non-substantive) to the screening and assessment section and NCQA requirement descriptions.

DHCS has redesigned the MCP requirements for developing a Population Needs Assessment (PNA), which has historically been MCPs' primary mechanism for identifying the priority health and social needs of their members, including health disparities. A central component of DHCS' approach is for MCPs to meaningfully participate on Local Health Jurisdiction (LHJ) Community Health Assessments (CHAs)/Community Health Improvement Plans (CHIPs) rather than complete a separate PNA focused solely on their own members' data. The updated PHM Policy Guide provides further operational details on MCPs' meaningful participation on LHJ CHAs/CHIPs.

Accompanying these PNA updates to the PHM Policy Guide, DHCS also released an MCP-LJH Collaboration Worksheet. The purpose of this Worksheet is to serve as a collaboration tool for MCPs to work and build relationships with LHJs and other MCPs in the same county early in the CHA/CHIP process. While DHCS requires this Worksheet be completed by August 1, 2024, the Worksheet will not be submitted to DHCS.

To also correspond with DHCS PHM PNA Policy Guide updates, CDPH has issued a memo to its LHJs on the alignment of MCP PNAs and LHJ Community Health Assessments.

If you have any questions, please contact the PHMSection@dhcs.ca.gov mailbox with the following subject line: "Modified PNA Requirements"

Risk Stratification, Segmentation, and Tiering (RSST) and Scientific Advisory Council (SciAC) Membership

On August 24, 2023, the California Department of Health Care Services (DHCS) released the membership of the Risk Stratification, Segmentation, and Tiering (RSST) Work Group (WG) and Scientific Advisory Council (SciAC). For more information, please view the Membership Announcement to find biographies, background information, and a description of the functions for the two groups.

2023 Population Health Management Strategy Template

On August 21, 2023 DHCS released the 2023 PHM Strategy Deliverable Template. The purpose of this annual deliverable is for MCPs to demonstrate meaningfully responding to community needs as well as to provide other updates on the PHM Program to inform DHCS' monitoring efforts. For 2023, the PHM Strategy Deliverable is intended to:

Ensure that certain National Committee for Quality Assurance (NCQA) requirements are being met.

Prepare MCPs for more robust collaboration with Local Health Departments (LHDs) that is to begin in 2024, when MCPs will be required to meaningfully participate in LHDs' community health assessments (CHAs) and community health improvement plans (CHIPs) in the service area(s) where MCPs operate.

Draft Member Contact and Demographic Information (MCDI) Initiative Strategy Document

On June 22, 2023, DHCS released the Draft Member Contact and Demographic Information (MCDI) Initiative Strategy Document for public comment. Medi-Cal members' contact and demographic information are critical components of Medi-Cal's efforts to enroll members, achieve health equity, and advance population health. Currently, stakeholders face a number of significant obstacles in their efforts to submit, collect, and use MCDI. The Draft MCDI Strategy provides a vision, goals, and measures of success to improve the collection, accessibility, quality, and use of MCDI and lays out a path to inform the future development of more detailed policy and operational plans.

DHCS welcomes feedback on the document and will accept public comment through 5 p.m. on July 6, 2023, to PHMSection@dhcs.ca.gov, with the subject line “Comments on Draft MCDI Strategy Document". In your feedback, we encourage you to identify the specific sections and page numbers for which you are providing comments.

Population Needs Assessment Concept Paper

On May 8, 2023, the California Department of Health Care Services (DHCS) released a concept paper describing its vision for a reimagined Population Needs Assessment (PNA) that Managed Care Plans (MCPs) are required to complete. DHCS envisions a modified PNA that promotes greater alignment with Local Health Departments and other community stakeholders, more robust community engagement, and a deeper understanding of member health and social needs and preferences and the communities in which they live. This approach is intended to facilitate better targeting of resources and interventions to support improved health outcomes for Medi-Cal members. DHCS is eager to engage with stakeholders on this vision and encourages feedback on the concept paper through written comments and/or by participating in forthcoming public forums and advisory groups. DHCS will accept public comment on the concept paper through June 2, 2023. Feedback should be submitted to PHMSection@dhcs.ca.gov with subject line “Comments on the PNA Concept Paper.

Final Population Health Management Strategy and Roadmap

On July 5, 2022, DHCS released the Final Population Health Management Strategy and Roadmap, which incorporates stakeholder feedback on all components of the PHM Framework. DHCS appreciates thoughtful comments from stakeholders that have helped to improve the Department's vision for PHM. As a reminder, DHCS will launch the PHM Program, a cornerstone of CalAIM, in January 2023. The PHM Program will establish a cohesive, statewide approach that ensures all Medi-Cal members have access to a comprehensive program that leads to longer, healthier and happier lives, improved health outcomes, and health equity. The Final Roadmap outlines key policy initiatives and accountability mechanisms, defines and describes PHM concepts and terminology, and details requirements for Medi-Cal managed care plans (MCMC Plans) for 2023 and 2024. The Final PHM Strategy and Roadmap is available at the DHCS CalAIM Population Health Management webpage. For any questions, please email CalAIM@dhcs.ca.gov

Key Documents

CalAIM Population Health Management Policy Guide - January 2024
MCP-LHJ Collaboration Worksheet - January 2024
Draft Member Contact and Demographic Information (MCDI) Initiative Strategy Document - June 2023
DHCS Concept Paper: Strengthening Medi-Cal Community Collaboration Through a Reimagined Population Needs Assessment - May 2023
CalAIM Population Health Management Frequently Asked Questions - June 2023
Population Health Management Program Readiness Deliverable Template - September 2022
Final Population Health Management Strategy and Roadmap - July 2022

Informational Webinars

To support stakeholder planning and implementation, DHCS hosts informational webinars to provide Population Health Management Program updates; meeting materials will be made available here following each webinar.

PHM All Comer Webinar: Updated Transitional Care Services (TCS) Policy

On Monday, January 22, 2024, DHCS held a webinar to provide an overview of recent updates to the Transitional Care Services policy, outlined in the Population Health Management Policy Guide.

The revised policy clarifies the requirements for high-risk members by updating the definition for high-risk groups, re-affirming DHCS' focus particularly on maternity care and populations with behavioral health needs, emphasizing MCP oversight on discharging facilities' discharge planning processes, and underscoring the importance of member engagement. The TCS policy for lower-risk members is also updated for 2024 and 2025 to provide member-centered transitional care support with a lighter-touch approach than the high-risk model. While the updated lower-risk model removes the single point of contact requirement, it does impose a clear but less staff-heavy requirement for a MCP Telephonic team to be available for all transitioning members and requires follow-up with a primary or ambulatory care provider within 30 days of discharge. It also emphasizes existing requirements on hospitals regarding the discharge process.

PHM All Comer Webinar: Emerging Practices on the Implementation of Transitional Care Services

On January 19, 2023, DHCS held an all-comer webinar on PHM Transitional Care Services under the PHM Program, a cornerstone of CalAIM.

Transitional Care Services support individuals undergoing a transition from one setting or level of care to another (e.g., discharge from hospital to home) to promote continuity of care and limit service disruptions. The webinar featured a panel discussion on emerging practices for implementing Transitional Care Services for high-risk members in 2023, and an overview of the latest requirements, including the phased implementation timeline.

PHM Service All Comer Webinar

On May 23, 2022 DHCS held an All-Comer Webinar to discuss DHCS's Population Health Management (PHM) Service.

As described in DHCS's recently released Draft Population Health Management Strategy and Roadmap , the PHM Service will support DHCS's vision for population heath management by: (1) collecting and integrating disparate information, (2) performing key population health management functions, and (3) providing authorized users with access to more timely, accurate, and comprehensive data on members' health history and needs. The webinar included a discussion of key planned functionalities of the PHM Service and time for Q&A.

Meeting and Materials

CalAIM Population Health Management Advisory Group

The PHM Advisory Group is comprised of cross-sector stakeholders who provide feedback and recommendations on many aspects of the CalAIM PHM program and the PHM Service. Members include a diverse set of leaders from across the state with representation from health plans, providers, counties, state departments, consumer organizations, and other groups. Specific topics for discussion will vary by meeting and will include screening and assessments, risk stratification and tiering, basic population health management, including wellness and prevention, care management, and patient engagement. While the PHM Advisory Group will be open to the public, active participation will be limited to Advisory Group members. The group will meet periodically through 2022.

Questions about the PHM Advisory Group may be directed to CalAIM@dhcs.ca.gov. To receive relevant updates on PHM Advisory Group meetings, sign up for DHCS Stakeholder Announcements.

Population Health Management Advisory Group Meeting Information

Upcoming Meetings

DHCS established the PHM Advisory Group to provide input to support the design and implementation of the PHM Program and Service. Members, which include representatives from health plans, providers, counties, state departments, consumer organizations, and other groups, will participate in Advisory Group meetings and provide real-time feedback and recommendations. The meetings are open to the public, and meeting information and materials will be available on the DHCS website. Stakeholders are encouraged to submit questions in advance of the webinar to PHMSection@dhcs.ca.gov.