CalAIM Population 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 tau tsim ib txoj kev npaj ua kom tiav, lav phib xaub rau cov tswv cuab cov kev xav tau thiab kev nyiam nyob thoob plaws qhov kev saib xyuas txuas ntxiv, uas yuav tsum muaj MCPs rau:
- Tsim kev ntseeg siab thiab muaj txiaj ntsig nrog cov tswv cuab.
- Sib sau, sib qhia, thiab tshuaj xyuas cov ntaub ntawv raws sij hawm thiab raug ntawm cov tswv cuab nyiam thiab xav tau los txheeb xyuas cov txiaj ntsig zoo thiab muaj txiaj ntsig zoo rau kev cuam tshuam los ntawm cov ntaub ntawv-tsav cov txheej txheem kev pheej hmoo stratification, kev kwv yees kwv yees, txheeb xyuas qhov tsis sib xws hauv kev saib xyuas, thiab cov txheej txheem ntsuam xyuas tus qauv.
- Tsom ntsoov rau txoj hauv kev nce toj uas txuas rau pej xeem kev noj qab haus huv thiab kev pabcuam pej xeem thiab txhawb cov tswvcuab noj qab haus huv los ntawm kev pabcuam kev noj qab haus huv thiab kev tiv thaiv.
- Muab kev tswj xyuas kev saib xyuas, kev sib koom tes saib xyuas, thiab kev saib xyuas kev hloov pauv thoob plaws hauv kev xa khoom, kev teeb tsa, thiab xwm txheej hauv lub neej.
- Txheeb xyuas thiab txo cov neeg tsav tsheb kev noj qab haus huv kom txo tau qhov tsis sib xws.
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.
Thaum PHM nthuav tawm, DHCS tab tom tsim PHM cov kev pabcuam, hu ua Medi-Cal Connect , uas yog ib qho kev daws teeb meem thoob plaws lub xeev los tsav PHM, kaw qhov khoob hauv cov kev pabcuam, thiab txhim kho cov tswvcuab lub neej.
- PHM Txoj Cai Qhia
- Kawm paub ntxiv txog Medi-Cal Connect.
- Download the factsheet about the CalAIM Population Health Management initiative.
- Nkag mus rau Phau Ntawv Qhia Txog Kev Pheej Hmoo, Kev Faib Tawm thiab Kev Ua Qib (RSST) Kev Pom Tseeb.
- Nkag mus rau Cov Lus Qhia Txog Kev Ua Haujlwm ntawm RSST Transparency Guide
Hloov tshiab tseem ceeb
Cov Kev Pabcuam Saib Xyuas Kev Hloov Chaw rau Cov Tswv Cuab Cev Xeeb Tub thiab Tom Qab Yug Me Nyuam Cov Kev Pabcuam Kev Txawj Ntse
Ua ib feem ntawm California txoj kev pab cuam Population Health Management (PHM), Medi-Cal Managed Care Plans (MCPs) muaj lub luag haujlwm los muab Transitional Care Services (TCS) los txhawb cov tswv cuab los ntawm kev hloov pauv tseem ceeb ntawm kev saib xyuas, suav nrog cov uas tshwm sim thaum cev xeeb tub thiab txog 12 lub hlis tom qab yug menyuam. DHCS tau hloov kho txoj cai TCS hauv Phau Ntawv Qhia Txoj Cai PHM thaum Lub Ib Hlis 2026 los txhawb kom muaj txiaj ntsig zoo rau kev noj qab haus huv ntawm niam, daws teeb meem kev mob nkeeg thiab kev tuag uas tiv thaiv tau, thiab ua raws li Txoj Kev Saib Xyuas Kev Yug Me Nyuam dav dua los ntawm kev tsim ob pawg, TCS siab thiab nruab nrab, uas ua tau raws li cov tswv cuab xav tau zoo dua thiab ua kom meej meej txog kev cia siab rau MCPs thiab cov kws kho mob perinatal. Cov ntaub ntawv hauv qab no tam sim no muaj los pab MCPs nrog kev ua haujlwm ntawm txoj cai TCS rau cov tswv cuab cev xeeb tub thiab tom qab yug menyuam.
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Kev Taug Kev ntawm Cov Tswv Cuab Thaum Cev Xeeb Tub thiab Tom Qab Yug Me Nyuam Uas Muaj Zog Heev - Ib qho piv txwv ntawm zaj dab neeg uas qhia txog seb MCP txheeb xyuas thiab txhawb nqa tus tswv cuab uas xav tau TCS uas muaj zog heev li cas, suav nrog kev txheeb xyuas cev xeeb tub thaum ntxov, kev muab tus Thawj Saib Xyuas Kev Kho Mob TCS, thiab kev sib koom tes thoob plaws kev xav tau kev kho mob, kev noj qab haus huv ntawm tus cwj pwm, thiab kev txhawb nqa hauv zej zog.
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Kev Taug Kev ntawm Cov Tswv Cuab Cev Xeeb Tub thiab Tom Qab Yug Me Nyuam Uas Muaj Zog Nruab Nrab - Ib txoj kev taug kev piav qhia txog kev ua haujlwm ntawm Tus Kws Saib Xyuas Neeg Mob Uas Muaj Ntawv Pov Thawj (CNM), uas tau cog lus ua lub koom haum sib koom tes saib xyuas TCS, xa cov kev pabcuam TCS uas muaj zog nruab nrab, suav nrog kev kuaj mob, kev xa mus, thiab kev koom ua ke ntawm Daim Ntawv Teev Cov Kev Pabcuam Yug Me Nyuam rau hauv kev saib xyuas niaj hnub.
- Daim Duab Qhia Txog Kev Mus Los ntawm Cov Tswv Cuab ntawm Kev Xeeb Tub thiab Tom Qab Yug Me Nyuam ntawm TCS - Ib daim duab yooj yim, ib nplooj ntawv uas txhais cov dab neeg txog kev mus los ntawm cov tswv cuab uas muaj zog thiab nruab nrab mus rau hauv daim duab meej thiab dav. Daim duab qhia txog cov ntsiab lus tseem ceeb ntawm kev hloov pauv, cov haujlwm TCS, lub luag haujlwm ntawm tus neeg muab kev pabcuam, thiab lub luag haujlwm ntawm MCP thoob plaws cev xeeb tub thiab tom qab yug menyuam, thiab tau tsim los txhawb kev cob qhia, kev sib txuas lus ntawm cov neeg koom nrog, thiab kev siv tau yooj yim thaum lub sijhawm siv.
- Daim Ntawv Teev Cov Kev Txhawb Nqa TCS Ntev - Daim ntawv teev cov kev txhawb nqa ua ntej yug menyuam mus rau tom qab yug menyuam uas qhia txog cov kev txhawb nqa TCS uas xav tau, suav nrog kev tshuaj xyuas, kev xa mus, thiab kev cia siab tom qab, siv los ntsuas cov kev xav tau ntawm cov tswv cuab thiab ua tiav cov luag haujlwm ntawm MCP thaum lub sijhawm hloov pauv kev saib xyuas.
Nyeem cov Lus Nug Txog Kev Xeeb Tub thiab Tom Qab Yug Me Nyuam TCS kom paub ntau ntxiv.
Community Reinvestment (CR) Txoj Cai thiab Cov Lus Nug Nquag
In February 2025, DHCS released All Plan Letter (APL) 25-004 on Community Reinvestment. The policy requires Medi-Cal Managed Care Plans (MCPs) to reinvest a portion of their annual net income into local communities to address unmet health-related social needs and support community wellbeing. The CR Frequently Asked Questions (FAQs) address common questions and provide additional guidance and clarification to support MCPs in implementing Community Reinvestment requirements.
PHM Key Performance Indicator Technical Specifications
DHCS released updated Technical Specifications for Key Performance Indicators (KPIs) in October 2025. These updates reflect the updated list of KPIs published in the July 2025 PHM Policy Guide and provide guidance to plans on how to correctly calculate the KPIs. Data collection will resume in January 2026, pursuant to Information Notice 25.001.
Phau Ntawv Qhia Txog Kev Pom Tseeb Txog Kev Pheej Hmoo, Kev Faib Pawg, thiab Kev Sib Tw (RSST)
DHCS has published the RSST Transparency Guide to provide a clear, public explanation of how the Risk Stratification, Segmentation, and Tiering (RSST) approach was developed and how it works. This Guide is published concurrently with the launch of Version 1 of RSST in Medi-Cal Connect. This resource outlines the design of Version 1 of the RSST algorithm, including the predictive models used, the tiering structure, and the methodology for assigning risk. The guide also details how RSST establishes a standardized definition of “high risk” across the state and invites feedback during this initial implementation phase to support future refinements.
Nkag mus rau RSST At-A-Graving
Hloov kho PHM Txoj Cai Qhia
Ib daim ntawv qhia tshiab ntawm Txoj Cai Tswjfwm Kev Noj Qab Haus Huv ntawm Cov Neeg (PHM) rau Cov Phiaj Xwm Kev Kho Mob tau muaj tam sim no. Cov kev hloov tshiab no qhia txog kev hloov pauv rau cov kev cai ntawm Kev Pabcuam Kev Hloov Chaw, Kev Npaj Hauv Zos thiab Txoj Cai PHM, Kev Faib Qib Kev Pheej Hmoo thiab Kev Faib Ua Pawg, cov kev cai ntawm Kev Teem Caij Kho Mob Thaum Pib, thiab suav nrog lub sijhawm hloov kho tshiab.
Kaw-Loop Referral (CLR) Kev Taw Qhia thiab Cov Lus Nug Nrho
Nyob rau lub Tsib Hlis 2025, DHCS tau tshaj tawm ib qho kev hloov kho tshiab ntawm Txoj Kev Xa Rov Qab Los Zej Zog (CLR) Kev Taw Qhia thiab Cov Lus Nug Nquag (FAQs). Cov kev hloov kho CLR Kev Taw Qhia Txog Kev Ua Haujlwm qhia txog cov kev xav tau rau MCPs hauv kev siv CLRs nyob rau hauv kev saib xyuas; suav nrog kev taug qab, txhawb nqa thiab saib xyuas CLRs. Cov kev hloov kho tshiab suav nrog kev qhia meej txog MCP cov cai ceeb toom, qhia meej tias CLR cov cai yuav tsis siv rau Sobering Centers tab sis yuav siv rau Kev Pabcuam Hloov Pauv Hauv Zej Zog thaum nws tso tawm, thiab suav nrog cov kev hloov kho me me thoob plaws. Cov FAQs pab txhawb MCPs hauv kev siv CLR thiab cov lus nug uas nquag nug txog kev siv, taug qab cov tswv cuab xa mus, thiab ceeb toom.
Read the Closed-Loop Referral (CLR) Implementation Guidance and CLR FAQs for more information.
Transitional Care Services Technical Assistance Resource
In August 2024, DHCS released a 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).
Risk Stratification, Segmentation, and Tiering (RSST) thiab Scientific Advisory Council (SciAC) Kev Koom Tes
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.
2025 Txhua Xyoo Kev Tswj Xyuas Kev Noj Qab Haus Huv Pej Xeem (PHM) Lub Tswv Yim xa tuaj
Per the PHM Policy Guide, MCPs are required to submit a PHM Strategy Deliverable (PHM SD) to DHCS annually. For the 2025 submission, MCP will complete the PHM SD through a Survey Monkey form by February 2, 2026. MCP should use the 2025 PHM SD Template (PDF) to review the questions and prepare their responses before completion of the Survey Monkey questionnaire.
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 2025, the PHM Strategy Deliverable is intended for MCPs to:
- Qhia tawm tshiab rau cov hom phiaj sib koom / SMART cov hom phiaj tsim los ntawm kev koom tes nrog LHJs rau 2023 DHCS PHM Strategy Deliverable;
- Share how they are meaningfully participating on LHJs’ CHAs and CHIPs, including bright spots and challenges;
- Qhia tawm tshiab txog kev nce qib mus rau 14 Lub Hom Phiaj Kev Noj Qab Haus Huv; thiab
- Ua pov thawj kom tiav NCQA PHM Strategy (nrog rau kev ntsuam xyuas NCQA cov pej xeem txhua xyoo) thiab muab cov kev hloov tshiab txij li thaum kawg xa mus rau DHCS.
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.
Cov Neeg Xav Tau Kev Soj Ntsuam Daim Ntawv Qhia
Thaum Lub Tsib Hlis 8, 2023, Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv California (DHCS) tau tshaj tawm ib tsab ntawv qhia txog nws lub zeem muag rau kev soj ntsuam cov neeg xav tau kev xav (PNA) uas yuav tsum tau ua kom tiav Cov Kev Npaj Kho Mob (MCPs) kom tiav. DHCS xav txog qhov hloov kho PNA uas txhawb nqa kev sib raug zoo nrog Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv Hauv Zos thiab lwm cov neeg koom nrog hauv zej zog, kev koom tes hauv zej zog muaj zog dua, thiab kev nkag siab tob txog cov tswv cuab kev noj qab haus huv thiab kev xav tau thiab kev nyiam thiab cov zej zog uas lawv nyob. Txoj hauv kev no yog tsim los pab txhawb kom lub hom phiaj zoo dua ntawm cov peev txheej thiab kev cuam tshuam los txhawb kev noj qab haus huv tau zoo dua rau cov tswv cuab Medi-Cal. DHCS tau mob siab los koom nrog cov neeg muaj feem cuam tshuam txog lub zeem muag no thiab txhawb kev tawm tswv yim ntawm cov ntawv tswv yim los ntawm cov lus sau thiab / lossis los ntawm kev koom nrog cov rooj sab laj pej xeem thiab pab pawg tawm tswv yim yav tom ntej. DHCS yuav lees txais cov lus tawm tswv yim rau pej xeem ntawm daim ntawv tswv yim txog thaum Lub Rau Hli 2, 2023. Cov lus qhia yuav tsum raug xa mus rau PHMSection@dhcs.ca.gov nrog cov kab ntawv "Cov Lus Qhia ntawm PNA Concept Paper.
Qhov Kawg Population Management Strategy thiab 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.
PHMD Cov Ntawv Ceeb Toom
PHMD Cov Ntawv Ceeb Toom Cov Ntaub Ntawv (IN) yog kev sib txuas lus los ntawm DHCS rau Managed Care Plans (MCPs) thiab cov neeg muaj feem, muab cov kev hloov tshiab tseem ceeb, cov lus qhia, thiab cov peev txheej rau Kev Tswj Xyuas Kev Noj Qab Haus Huv Pej Xeem (PHM). Pib txij lub Kaum Ib Hlis 2024, DHCS yuav tshaj tawm tag nrho cov ntawv tshaj tawm tshiab PHMD IN ntawm DHCS lub vev xaib kom nkag tau yooj yim los ntawm MCPs thiab cov neeg koom nrog.
PHMD IN#: 25.003 – PHM KPI Technical Specification Updates
PHMD IN #: 25.002 -Submission Instructions for 2025 PHM Strategy Deliverable
PHMD IN#: 25.001 – Updated Submission Instructions for PHM Key Performance Indicators (KPIs)
PHMD IN#: 24.001 – Updated Submission Instructions for PHM Strategy Deliverable – October 2024
Cov ntaub ntawv tseem ceeb
- Phau Ntawv Qhia Txog Txoj Cai Tswjfwm Kev Noj Qab Haus Huv ntawm CalAIM
- 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 Kev Tswj Xyuas Kev Noj Qab Haus Huv Pej Xeem Cov Lus Nug Nrho-Lub Rau Hli 2024
- Population Health Management Program Readiness Deliverable Template – September 2022
- Final Population Health Management Strategy and Roadmap – July 2022
Cov ntaub ntawv 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: Kaw-Loop Referral Implementation Guide
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: Txhawb Medi-Cal Cov Tswv Cuab nrog Kev Pabcuam Sijhawm Ntev thiab Kev Txhawb Nqa (LTSS) Xav Tau Kev Pabcuam Hloov Kho
Hnub Wednesday, Lub Yim Hli 21 los ntawm, DHCS tau tuav lub vev xaib hais txog kev txhim kho cov kev pabcuam thiab kev txhawb nqa muaj rau Cov Tswvcuab nrog LTSS xav tau thaum lawv ntsib kev hloov pauv ntawm kev saib xyuas. Kev hloov pauv ntawm kev saib xyuas tshwm sim thaum tus tswvcuab hloov chaw los ntawm ib qho chaw lossis qhov chaw saib xyuas mus rau lwm qhov, xws li tso tawm hauv tsev kho mob mus rau qhov chaw saib xyuas neeg mob (SNF) lossis los ntawm SNF mus rau ib lub tsev lossis chaw nyob hauv zej zog. Raws li CalAIM PHM qhov kev pab cuam, Managed Care Plans (MCPs) yog lub luag haujlwm xa cov kev pabcuam kev saib xyuas kev hloov pauv kom ntseeg tau tias cov tswvcuab tau txais kev txhawb nqa txij thaum pib cov txheej txheem kev npaj tawm mus, dhau ntawm lawv txoj kev hloov mus, kom txog rau thaum lawv tau txuas nrog txhua qhov kev pabcuam thiab kev txhawb nqa uas xav tau. Vim muaj ntau yam thiab tsis yooj yim ntawm cov kev pab cuam muaj rau cov pej xeem LTSS thoob plaws Medi-Cal, cov neeg muaj feem tau thov kev pab cuam los xyuas kom meej tias muaj kev hloov pauv mus rau qib kev saib xyuas tsawg kawg nkaus. Thaum kev tso npe qhib rau txhua tus neeg uas txaus siab, qhov kev tshwm sim no yuav muaj txiaj ntsig tshwj xeeb rau MCP thiab cov neeg ua haujlwm kho mob lub luag haujlwm rau kev saib xyuas rau Cov Tswv Cuab nrog LTSS xav tau.
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: Hloov Kho Kev Pabcuam Kev Khomob (TCS) Txoj Cai
DHCS Tshaj Tawm Tshiab Kev Pabcuam Kev Pabcuam Kev Pabcuam Kev Pabcuam Kev Pabcuam 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 Tag Nrho Cov Neeg Tuaj Webinar: Cov Txheej Txheem Tshaj Tawm ntawm Kev Siv Cov Kev Pabcuam Hloov Kho
Thaum Lub Ib Hlis Ntuj Tim 19, 2023, DHCS tau tuav ib qho kev sib tham hauv webinar ntawm PHM Transitional Care Services raws li PHM Program, lub hauv paus ntawm CalAIM.
Transitional Care Services txhawb cov tib neeg uas tau hloov pauv los ntawm ib qho chaw lossis theem kev saib xyuas mus rau lwm qhov (piv txwv li, tawm hauv tsev kho mob mus rau tsev) los txhawb kev saib xyuas txuas ntxiv thiab txwv kev cuam tshuam txog kev pabcuam. Lub webinar qhia txog kev sib tham txog cov kev coj ua tshiab rau kev siv Kev Pabcuam Kev Khomob rau cov tswvcuab uas muaj kev pheej hmoo siab hauv xyoo 2023, thiab cov ntsiab lus ntawm cov kev xav tau tshiab kawg, suav nrog cov sijhawm ua ntu zus.
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.
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CalAIM Population 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.
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Joint CalAIM Children & Youth and PHM Advisory Group Meeting – October 2024
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
Joint CalAIM Children & Youth and PHM Advisory Group Meeting – April 2024
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
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PHM Advisory Group Meeting # 11 – October 2023
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Lot
PHM Advisory Group Meeting # 10 – July 2023
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
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PHM Advisory Group Meeting # 7 – December 2022
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
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PHM Advisory Group Meeting #4 – July 2022
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
PHM Advisory Group Meeting #3 – May 2022
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log
PHM Advisory Group Meeting #2 – April 2022
Presentation Slides
Recording
Key Takeaways
Transcript
Launch of PHM Advisory Group Meeting – March 2022
Presentation Slides
Recording
Transcript
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Medi-Cal Connect
Population Health Management Factsheet
Population Health Management Q&A with Dr. Palav Babaria, Chief Quality Officer and Deputy Director of Quality and Population Health Management at DHCS
Comprehensive Quality Strategy (CQS)
Risk Stratification, Segmentation, and Tiering (RSST) and Scientific Advisory Council (SciAC) Membership Announcement
Medi-Cal’s Strategy to Support Health and Opportunity for Children and Families
Enhanced Care Management (ECM) and Community Supports Information
Materials from 2019 Population Health Management Strategy Workgroup
Medi-Cal’s Strategy to Support Health and Opportunity for Children and Families Webinar: DHCS shared more about the strategy to support children and families enrolled in Medi-Cal that will unify the common threads of existing and newly proposed child and family health initiatives and strengthen DHCS’ accountability and oversight of children’s services. Presenters provided an overview of eight action areas and detailed initiatives underpinning DHCS’ strategy and expected timelines and responded to attendee questions. (March 14, 2022)
Review the webinar presentation slides, recording, and transcript.
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Contact DHCS with any questions or comments on the CalAIM Population Health Management initiatives at PHMSection@dhcs.ca.gov.