PHMI Regional CHC Learning Session
By Cristian Vargas, Quality Improvement Program Coordinator
Central Valley Health Network
The Population Health Management Initiative (PHMI) is a California collaboration between the Department of Health Care Services (DHCS), Kaiser Permanente, and Community Health Centers (CHCs).
On June 25, more than 40 representatives from Clinica Sierra Vista, Community Medical Centers, Golden Valley Health Centers, OMNI Family Health, Central Valley Health Network (CVHN), DHCS, and the PHMI Program Office came together for a day-long regional learning session designed to build a community of peers, identify promising practices, and emerging challenges within their population health management journeys. The convening highlighted tailored topics unique to the needs of participating health centers in the Central Valley region as they transition over to the next phase of the initiative, which included addressing health-related social needs in their populations of focus, medical assistant retention or role development, and how to support care coordination.
Building on the social health competency outlined in the PHMI Populations of Focus (PoF) implementation guides, participating CHCs gained insights on how to develop their social screening and referral processes to inform care plans that equitably address their patients’ social needs. CHC team members brainstormed the current nature of their own community-based connections and the type of services that these organizations can offer through strategic partnerships. At the consortia level, CVHN contributed to CHCs’ progress with improving access to local social health supports by creating a resource list encompassing over 110 community-based organizations (CBOs). This extensive roster includes local Enhanced Care Management and Community Support providers contracted to managed care plans and non-contracted locations across the San Joaquin, Stanislaus, and Kern counties.
Leveraging the PHMI Social Health framework, Robin Haller, the Social Health Subject Matter Expert Lead shared a roadmap approach on how to identify health-related social needs of sub-populations and workflows that develop the key elements of social health integration into their primary care practices. Another bright spot of the session focused on care coordination optimization and how health centers can work alongside external partners to streamline high quality referrals and transitions for high-risk patients. At the core of these topics is our healthcare workforce which enables health centers to sustain their population health management objectives and patient-centered care values. Through a session exploring Medical Assistant role development and career advancement, stakeholders learned about practical opportunities to upskill MAs while achieving long-term diversity and continuity of care goals within the communities they serve.
On a day of learning, engagement, and synergy, CHCs received the opportunity to Mingo, a Bingo-inspired game where participants identify other colleagues who meet one of the descriptions in a table of squares (and compete to fill 5 sequential squares first!). Every PHMI implementation team will now begin prioritizing key activities and foundational competencies to develop a 90-day aim statement that aligns with their target population. As a testament to the success of the regional learning session, Alyssa Lopez, Senior Director of Quality Improvement at Community Medical Centers shared, “The PHMI Regional CHC Learning Session in Fresno was a great way to learn from our fellow colleagues and their population of focus. It was also good to interact with our PHMI coaches, breakout groups, and the activities that were beneficial to all.”
The next regional learning session will take place with Aliados Health and their participating CHCs in PHMI on August 29 in Santa Rosa, CA. For more information about PHMI, please visit www.phminitiative.com.