首页CalAIM：改革加州医保CalAIM 人口健康管理倡议​​ 

CalAIM 人口健康管理计划​​ 

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 制定了一套全面、负责的行动计划，用于解决整个护理过程中会员的需求和偏好，该计划要求 MCP：​​ 

  • 建立信任并与成员进行有意义的互动。​​ 
  • 收集、共享和评估有关会员偏好和需求的及时和准确的数据，以通过数据驱动的风险分层流程、预测分析、识别护理差距和标准化评估流程来确定有效干预的机会。​​ 
  • 重点关注与公共卫生和社会服务相关的上游方法，并通过健康和预防服务支持会员保持健康。​​ 
  • 提供跨护理系统、环境和生活环境的护理管理、护理协调和护理转变。​​ 
  • 识别并减轻影响健康的社会驱动因素，以减少差距。​​ 

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.​​   

在 PHM 推出的同时，DHCS 正在开发一项名为Medi-Cal Connect的 PHM 服务，这是一项创新的全州数据解决方案，旨在推动 PHM、缩小服务差距并改善会员生活。​​ 

重要更新​​ 

为怀孕和产后会员提供的过渡性护理服务 技术援助资源​​  

作为加州人口健康管理 (PHM) 计划的一部分，加州医疗管理计划 (MCP) 负责提供过渡性护理服务 (TCS)，以支持会员完成关键的护理过渡，包括怀孕期间和产后 12 个月内的护理过渡。2026 年 1 月，DHCS 更新了 PHM 政策指南中的 TCS 政策，以加强孕产妇健康成果，解决可预防的发病率和死亡率问题，并与更广泛的 "分娩护理途径 "保持一致，建立了高强度和中等强度的 TCS 两个类别，以更好地满足会员需求，并明确对 MCP 和围产期医疗服务提供者的期望。现提供以下材料，以协助医保计划为怀孕和产后会员实施临时医护服务政策。​​   

  • 高强度妊娠和产后会员旅程- 一个叙述性案例，说明 MCP 如何识别和支持需要高强度 TCS 的会员，包括早期妊娠识别、指派 TCS 护理经理，以及协调医疗需求、行为健康和社会支持。​​  

  • 中等强度的妊娠和产后会员旅程- 描述了注册助产士 (CNM) 如何作为 TCS 护理协调实体，提供中等强度的 TCS，包括筛查、转诊以及将分娩支持清单纳入常规护理。​​  

  • 孕期和产后 TCS 会员旅程视觉图- 精简的单页视觉图，将高强度和中等强度的会员旅程叙述转化为清晰、全面的图表。该视频突出了整个孕期和产后的关键过渡点、技术服务支持活动、医疗服务提供者的角色以及产妇保健计划的责任，旨在支持培训、利益相关者沟通以及在实施过程中便于参考。​​  
  • 长式 TCS 生育支持核对表- 全面的产前至产后核对表，概述了所需的 TCS 支持，包括筛查、转诊和后续期望，用于评估会员需求和履行 MCP 在护理过渡期间的责任。​​  

阅读《孕期和产后 TCS 常见问题解答》，了解更多信息。​​ 

社区再投资 (CR) 政策和常见问题​​  

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 关键性能指标技术规格​​  

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.​​  

风险分层、细分和分级 (RSST) 透明度指南​​   

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.​​  

访问 RSST 一览​​ 

更新的 PHM 政策指南​​ 

管理式医疗计划人口健康管理(PHM) 政策指南》更新版现已发布。这些更新反映了过渡性护理服务要求、地方规划和 PHM 战略、风险分层和细分、初次健康预约要求的变化，并包括最新的实施时间表。​​   

闭环转诊 (CLR) 实施指南和常见问题解答​​ 

2025 年 5 月，DHCS 发布了闭环转诊 (CLR) 实施指南和常见问题 (FAQ) 的更新版本。更新后的 CLR 实施指南概述了 MCP 在管理式医疗下实施 CLR 的要求；包括跟踪、支持和监控 CLR。更新包括澄清 MCP 通知要求、指定 CLR 要求不适用于清醒中心但将适用于启动后的过渡租金社区支持，并在整个过程中纳入小的格式更新。常见问题解答有助于支持 MCP 实施 CLR，并解决与实施、跟踪会员推荐和通知相关的常见问题。​​ 

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

过渡性护理服务技术援助资源​​   

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).​​ 

风险分层、细分和分级 (RSST) 和科学咨询委员会 (SciAC) 成员资格​​ 

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 年度人口健康管理（PHM）战略交付成果​​ 

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:​​ 

  • 分享与 LHJs 合作为 2023 年 DHCS PHM 战略可交付成果制定的共享目标/SMART 目标的更新；​​  
  • Share how they are meaningfully participating on LHJs’ CHAs and CHIPs, including bright spots and challenges;​​  
  • 分享实现 14 项行为健康目标的最新进展情况；以及​​  
  • 证明已完成 NCQA PHM 战略（包括年度 NCQA 人口评估），并提供自上次提交 DHCS 以来的更新信息。​​  

会员联系和人口统计信息 (MCDI) 倡议战略文件草案​​ 

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.​​ 

人口需求评估概念文件​​ 

2023 年 5 月 8 日，加州卫生保健服务部 (DHCS) 发布了一份概念文件，描述了其对管理式医疗计划 (MCP) 必须完成的重新构想的人口需求评估 (PNA) 的愿景。 DHCS 设想修改后的 PNA，以促进与地方卫生部门和其他社区利益相关者的更大协调、更强劲的社区参与，以及更深入地了解成员的健康和社会需求和偏好以及他们所居住的社区。 这种方法旨在促进更好地定位资源和干预措施，以支持 Medi-Cal 成员改善健康状况。 DHCS 渴望与利益相关者就这一愿景进行交流，并鼓励通过书面评论和/或参加即将举行的公共论坛和咨询小组对概念文件提出反馈。 DHCS 将在2023 年 6 月 2 日之前接受公众对概念文件的评论。反馈意见应提交至PHMSection@dhcs.ca.gov ，主题为“对 PNA 概念文件的评论”。​​ 

最终人口健康管理战略和路线图​​ 

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 信息通知​​ 

PHMD 信息通知 (IN) 是 DHCS 向管理式医疗计划 (MCP) 和利益相关者发布的官方信息，提供有关人口健康管理 (PHM) 计划的重要更新、指南和资源。从2024年11月开始，健康与医疗服务部将在健康与医疗服务部网站上公布所有新发布的《公共健康和医疗服务指示》，以方便医疗保健中心和利益相关者查阅。​​  

PHMD IN# 26.001：2026 年 4 月 PHM KPI 技术规格更新​​ 

PHMD IN#: 25.003 – PHM KPI Technical Specification Updates​​ 

PHMD IN#: 25.002 - 2025 PHM 战略可交付成果的提交说明​​ 

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​​ 

重要文件​​ 

信息网络研讨会​​ 

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 网络研讨会：闭环转诊实施指南​​ 

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.​​ 

前列腺增生症​​  网络研讨会：​​  为 Medi-Cal 会员提供长期服务和支持 (LTSS) 需要经历护理过渡​​ 

8 月 21 日星期三，DHCS 举办了一场网络研讨会，讨论如何在需要 LTSS 的会员经历护理转变时为他们提供更好的服务和支持。 护理转变发生在会员从一种护理环境或护理地点转移到另一种护理环境或护理地点时，例如从医院出院转移到专业护理机构 (SNF) 或从 SNF 出院转移到家庭或社区环境。 根据 CalAIM PHM 计划，管理式护理计划 (MCP) 负责提供过渡护理服务，以确保会员从出院计划流程开始、过渡期间一直到成功获得所有所需的服务和支持都得到支持。 鉴于 Medi-Cal 为 LTSS 人群提供的服务的多样性和复杂性，利益相关者已请求技术援助，以确保成功过渡到限制最少的护理级别。 虽然所有感兴趣的人都可以报名，但这次活动对 MCP 和负责为有 LTSS 需求的会员提供护理管理的医疗机构工作人员特别有益。​​ 

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 网络研讨会：更新的过渡护理服务 (TCS) 政策​​ 

DHCS 发布新的过渡护理服务技术援助资源​​  用于 LTSS 转换的 TCS TA 资源。​​ 
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 网络研讨会：过渡性护理服务实施的新兴实践​​ 

2023 年 1 月 19 日，DHCS 举办了一场关于 PHM 计划下的 PHM 过渡护理服务的网络研讨会，该计划是 CalAIM 的基石。​​ 

过渡性护理服务支持个人从一种环境或护理级别过渡到另一种环境或护理级别（例如从医院出院回家），以促进护理的连续性并限制服务中断。 网络研讨会以小组讨论的形式，探讨了 2023 年为高危成员实施过渡护理服务的新兴实践，并概述了最新要求，包括分阶段实施的时间表。​​  

PHM 服务全员网络研讨会​​ 

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.​​ 

会议及资料​​ 

CalAIM 人口健康管理咨询小组​​ 

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.​​ 

CalAIM 人口健康管理咨询小组会议信息​​ 

过去的会议和材料​​ 

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​​ 

PHM咨询小组第13次会议 – 2024年2月
演示文稿
录音
主要内容
文字稿{
聊天记录
PHM咨询小组第12次会议 – 2023年12月
演示文稿
录音
主要内容
文字稿
聊天记录​​ 

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​​ 

PHM 咨询小组第 9 次会议 -2023 年 4 月
演示幻灯片
录音
主要收获
文字记录
聊天记录
PHM 咨询小组第 8 次会议 - 2023 年2 月
演示幻灯片
录音
主要收获
文字记录
聊天记录​​ 

PHM Advisory Group Meeting # 7 – December 2022
Presentation Slides
Recording
Key Takeaways
Transcript
Chat Log​​ 

PHM 咨询小组第 6 次会议 -2022 年 10 月
演示幻灯片
录音
主要收获
文字记录
聊天记录
PHM 咨询小组第 5 次会议 - 2022 年9 月
演示幻灯片
记录
主要收获
文字记录
聊天记录​​ 

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​​ 

其他资源​​ 

下面列出了有关人口健康管理的关键信息的附加资源。​​ 

Medi-Cal Connect​​ 
人口健康管理情况说明书​​ 
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.​​ 

问题和评论​​ 

Contact DHCS with any questions or comments on the CalAIM Population Health Management initiatives at PHMSection@dhcs.ca.gov.​​