CalAIM Population Health Management Initiative

In 2023, DHCS launched Population Health Management (PHM), a cornerstone of CalAIM.

PHM establishes 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 PHM's key elements were already in place in the Medi-Cal program prior to CalAIM through both DHCS policies and Medi-Cal managed care plans' (MCP) procedures and programs. Under PHM, MCPs 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 developed a comprehensive, accountable plan of action for addressing member needs and preferences across the continuum of care, which requires MCPs 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 support members staying healthy through wellness and prevention services.
Provide care management, care coordination, and care transitions across delivery systems, settings, and life circumstances.
Identify and mitigate social drivers of health to reduce disparities.

Beginning in 2023, all MCPs must meet the National Committee for Quality Assurance's standards for PHM as well as additional DHCS statewide PHM standards that are aligned with the requirements listed above.

PHM is designed to proactively assess and address the care needs of Medi-Cal members with tailored interventions. MCPs are now responsible for the care of more than 90 percent of Medi-Cal members. Establishing a unified, statewide approach to PHM ensures 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, including Enhanced Care Management (ECM) and Community Support. This change is also further articulated in DHCS' Comprehensive Quality Strategy (CQS), as well as Medi-Cal's Strategy to Support Health and Opportunity for Children and Families.

While PHM rolls out, DHCS is developing a PHM service, called Medi-Cal Connect , which is an innovative statewide data solution to drive PHM, close gaps in services, and improve member lives.

Download the factsheet about the CalAIM Population Health Management initiative.

Important Updates

Updated PHM Policy Guide

DHCS has released updates to the PHM Policy Guide. These updates reflect the newly released requirements outlined in the Closed-Loop Referrals Implementation Guidance, and make minor stylistic and clarifying edits to the Population Needs Assessment (PNA) and PHM Strategy section.

Closed-Loop Referral (CLR) Implementation Guidance

The Department of Health Care Services (DHCS) is pleased to announce the release of the Closed-Loop Referral (CLR) Implementation Guidance. The CLR Implementation Guidance outlines requirements for MCPs in implementing CLRs under managed care; including tracking, supporting and monitoring CLRs. This new requirement aims in ensuring more members are connected to needed care by identifying and addressing gaps in referral paths.

Read the Closed-Loop Referral (CLR) Implementation Guidance for more information.

Medi-Cal Connect Webinar Frequently Asked Questions (FAQs)

In May 2024, DHCS held two webinars to introduce Medi-Cal Connect, one for Medi-Cal managed care plans and one for stakeholders. DHCS compiled questions raised by webinar participants and developed FAQs to address common themes. Read the Medi-Cal Connect FAQs for more information.

New Transitional Care Services Technical Assistance Resource

On August 20, DHCS released a new technical assistance resource dedicated to ensuring successful Transitional Care Services (TCS) for Medi-Cal Members with Long-Term Services and Supports (LTSS) needs. Under the CalAIM PHM program, Managed Care Plans (MCPs) are responsible for delivering TCS to ensure Members are supported from the start of the discharge planning process, through their transition, until they have been successfully connected to all needed services and supports. MCPs have flexibilities to leverage different services and supports to meet each individual's unique circumstances. DHCS' vision is that Medi-Cal members requiring LTSS can remain in the least restrictive setting that meets their preferences, needs, and optimizes their quality of life. Transitions of care occur when a member transfers from one setting or location of care to another, like a discharge from a hospital to a skilled nursing facility (SNF) or from a SNF to a home or community-based setting. Given the variety and complexity of available services and supports for this population across the Medi-Cal program, DHCS has developed this new TCS Technical Assistance Resource for Medi-Cal MCPs intended to provide concrete promising practices from the field to demonstrate how MCPs can best support their members with LTSS needs undergoing transitions of care. It sets out to enhance MCPs' foundational understanding of different LTSS programs and resources that MCPs can consider and adopt in their own workflows and ensure successful transitions into the least restrictive level of care (LOC).

Medi-Cal Connect: Release One

On July 25, 2024, DHCS began the first phase of its rollout of Medi-Cal Connect. Medi-Cal Connect combines data from reliable sources to give a full view of a person's benefits and health. It also helps understand overall trends to improve policies and programs. The first two phases are for DHCS staff only. Future planned phases will involve MCPs, providers, and finally, Medi-Cal members. Each phase will collect feedback from users to develop and improve the program and its functions. For a more detailed timeline, visit What is Medi-Cal Connect.

PHMD Information Notices

PHMD Information Notices (IN) are official communications from DHCS to Managed Care Plans (MCPs) and stakeholders, providing essential updates, guidelines, and resources for the Population Health Management (PHM) program. Starting in November 2024, DHCS will post all newly issued PHMD IN on the DHCS website for easy access by MCPs and stakeholders.

PHMD IN#: 24.001 - Updated Submission Instructions for PHM Strategy Deliverable - October 2024

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.

2024 Annual Population Health Management (PHM) Strategy Deliverable

Per the PHM Policy Guide, MCPs are required to submit their annual DHCS PHM Strategy Deliverable by end of day October 31, 2024. MCPs should use the Submission Instructions, Part 1 Template, Part 2 Template to complete their submissions.

The purpose of this annual deliverable is to update DHCS on MCPs' PHM programs, including the progress of MCPs' meaningful participation in the Community Health Assessments (CHAs)/and Community Health Improvement Plans (CHIPs) conducted by Local Health Jurisdictions (LHJs) in the service areas where MCPs operate. The MCP-LHJ collaboration on the CHA/CHIP will enhance MCPs' ability to identify needs and strengths within members' communities so that MCPs and their community partners can reduce siloed approaches to population health management and more effectively improve the lives of members. For 2024, the PHM Strategy Deliverable is intended for MCPs to:

Share updates to the shared goal/SMART objective developed in collaboration with LHJs for the 2023 DHCS PHM Strategy Deliverable
Share how they are meaningfully participating on LHJs' CHAs and CHIPs, including bright spots and challenges
Attest to completion of the NCQA PHM Strategy (inclusive of annual NCQA population assessment) and provide updates since last submitted to DHCS
Share updates on progress toward Key Performance Indicators and DHCS Bold Goals

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 PHMSection@dhcs.ca.gov.

Key Documents

CalAIM Population Health Management Policy Guide - January 2025
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 2024
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: Closed-Loop Referral Implementation Guidance

On February 13, 2025, DHCS hosted an All-Comer Webinar to discuss the requirements outlined in the recently released Closed-Loop Referral (CLR) Implementation Guidance. CLR requirements aim to increase the share of Medi-Cal Members successfully connected to the services they need. By improving their information collection processes, MCPs will be able to better support individual referrals and address system-level gaps in referral practices and service availability that impact Members. MCPs must implement CLR requirements by July 1, 2025 for two priority services – Enhanced Care Management (ECM) and Community Supports. During the webinar, Dr. Palav Babaria discussed DHCS's motivation for developing CLR requirements, provided an overview of the CLR definition, goals, and applicable services, and concluded with a detailed CLR scenario for a referral to the Medically Tailored Meals Community Support.

PHM Webinar: Supporting Medi-Cal Members with Long-Term Services and Supports (LTSS) Needs Experiencing Transitions of Care

On Wednesday, August 21 from, DHCS held a webinar about improving services and supports available to Members with LTSS needs as they experience transitions of care. Transitions of care occur when a member transfers from one setting or location of care to another, like a discharge from a hospital to a skilled nursing facility (SNF) or from a SNF to a home or community-based setting. Under the CalAIM PHM program, Managed Care Plans (MCPs) are responsible for delivering transitional care services to ensure Members are supported from the start of the discharge planning process, through their transition, until they have been successfully connected to all needed services and supports. Given the variety and complexity of available services for the LTSS population across Medi-Cal, stakeholders have requested technical assistance to ensure successful transitions into the least restrictive level of care. While registration is open to all those who are interested, this event will be particularly beneficial to MCP and health care facility staff responsible for care management for Members with LTSS needs.

This webinar focused on how Community Supports, Enhanced Care Management (ECM), and Transitional Care Services (TCS) can be integrated to best support Members during and after periods of transition. Anwar Zoueihid, the Vice President of LTSS at Partners in Care Foundation, and Chris Esguerra, the Chief Medical Officer at Health Plan of San Mateo, will join DHCS as guest speakers for a fireside chat during the event to share promising practices for successful transitions for this population. The webinar will highlight new resources including the recently released ECM Long-Term Care Population of Focus Spotlight and the forthcoming TCS Technical Assistance Resource Guide for Members with LTSS needs.

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

DHCS Releases New Transitional Care Services Technical Assistance Resource TCS TA Resource for LTSS Transitions.
On August 20, DHCS released a new technical assistance resource dedicated to ensuring successful Transitional Care Services (TCS) for Medi-Cal Members with Long-Term Services and Supports (LTSS) needs. Under the CalAIM PHM program, Managed Care Plans (MCPs) are responsible for delivering TCS to ensure Members are supported from the start of the discharge planning process, through their transition, until they have been successfully connected to all needed services and supports. MCPs have flexibilities to leverage different services and supports to meet each individual's unique circumstances. DHCS' vision is that Medi-Cal members requiring LTSS can remain in the least restrictive setting that meets their preferences, needs, and optimizes their quality of life. Transitions of care occur when a member transfers from one setting or location of care to another, like a discharge from a hospital to a skilled nursing facility (SNF) or from a SNF to a home or community-based setting. Given the variety and complexity of available services and supports for this population across the Medi-Cal program, DHCS has developed this new TCS Technical Assistance Resource for Medi-Cal MCPs intended to provide concrete promising practices from the field to demonstrate how MCPs can best support their members with LTSS needs undergoing transitions of care. It sets out to enhance MCPs' foundational understanding of different LTSS programs and resources that MCPs can consider and adopt in their own workflows and ensure successful transitions into the least restrictive level of care (LOC).

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, which met from 2022-2024, was comprised of cross-sector stakeholders who provided feedback and recommendations on many aspects of the CalAIM PHM Program and PHM Service (Medi-Cal Connect). Members included a diverse set of leaders from across the state with representation from health plans, providers, counties, state departments, consumer organizations, and other groups. Meeting topics included screening and assessments, risk stratification and tiering, basic population health management, including wellness and prevention, care management, and patient engagement.