首頁CalAIM: Medi-Cal 轉型CalAIM 人口健康管理計畫​​ 

卡拉伊姆人口健康管理倡議​​ 

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 制定了一個全面、負責任的行動計劃，以滿足成員的持續護理期間的需求和偏好，這要求 MCP 必須：​​ 

  • 建立信任並與會員有意義的互動。​​ 
  • 收集、分享和評估有關會員偏好和需求的及時準確數據，以透過資料驅動的風險分層流程、預測分析、識別護理差距和標準化評估流程，找出有效率和有效的干預機。​​ 
  • 專注於與公共衛生和社會服務相關的上游方法，並通過健康和預防服務支持成員保持健康。​​ 
  • 提供跨遞系統、環境和生活環境的照護管理、護理協調和護理轉換。​​ 
  • 識別和緩解健康的社會驅動因素，以減少差異。​​ 

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 推出時，DHCS 正在開發一項名為 Medi-Cal Connect 的 PHM 服務，該服務是一種創新的全州數據解決方案，可以推動 PHM，彌補服務差距並改善會員生活。​​ 

重要更新​​ 

懷孕和產後會員的過渡性照護服務 技術協助資源​​  

作為加州人口健康管理 (PHM) 計劃的一部分，加州醫療保險管理性護理計劃 (MCP) 負責提供過渡性照護服務 (TCS)，以支援會員完成關鍵性的照護過渡，包括在懷孕期間及產後 12 個月內發生的過渡。DHCS 於 2026 年 1 月更新了 PHM 政策指南中的 TCS 政策，以加強孕產婦健康成果、解決可預防的發病率和死亡率問題，並與更廣泛的分娩照護途徑保持一致，建立了高強度和中等強度 TCS 兩個類別，以更好地滿足會員需求，並澄清對 MCP 和圍產期醫療服務提供者的期望。現提供下列資料，以協助 MCP 實施針對懷孕和產後會員的 TCS 政策。​​   

  • 高強度的懷孕和產後會員旅程- 說明 MCP 如何識別和支援需要高強度 TCS 的會員的敘述性案例，包括早期懷孕識別、指派 TCS 護理經理，以及協調醫療需求、行為健康和社會支援。​​  

  • 中度強度的懷孕與產後會員旅程- 描述註冊助產士 (CNM) 如何以 TCS 護理協調實體的簽約方式，提供中度強度的 TCS，包括篩檢、轉診，以及將 Birthing Supports Checklist 整合到例行護理中。​​  

  • 懷孕和產後服務 TCS 會員旅程視覺- 簡化的單頁視覺，將高強度和中等強度的會員旅程敘述轉換成清晰、全面的圖表。該視覺化資料強調了整個孕期和產後的關鍵轉換點、TCS 活動、醫療服務提供者角色和 MCP 責任，其設計目的在於支援訓練、利害關係人溝通，以及在實施過程中方便參考。​​  
  • 長版 TCS 分娩支持清單– 一份全面的產前到產後清單，概述了所需的 TCS 支持，包括篩檢、轉診和後續期望，用於評估會員需求並在護理過渡期間履行 MCP 職責。​​  

閱讀「懷孕與產後 TCS 常見問題」以獲得更多資訊。​​ 

社區再投資 (CR) 政策和常見問題​​  

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 關鍵性能指標技術規格​​  

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.​​  

風險分層、區隔和分級 (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.​​  

存取 RSST 一覽表​​ 

更新的 PHM 政策指南​​ 

管理式保健計劃的人口健康管理(PHM) 政策指南更新版現已推出。這些更新反映了過渡性照護服務要求、當地規劃與 PHM 策略、風險分層與區隔、初次健康預約要求的變更，並包括更新的實施時間表。​​   

封閉迴路轉介 (CLR) 實施指引及常見問題​​ 

2025 年 5 月，DHCS 發布了封閉循環轉介（CLR）實施指南和常見問題（常見問題）的更新版本。更新的 CLR 實施指引概述了 MCP 在受管理照護下實施 CLR 的要求，包括跟踪、支持和監控 CLR。更新包括澄清 MCP 注意要求，指明 CLR 要求將不適用於醒神中心，而將適用於過渡性租金社區支持服務時，並在整個過渡性租金社區支持中心應用，並在整個過程中加入小型格式更新。常見問題解答有助於支持 MCP 實施 CLR，並解決與實施、追蹤成員推薦和注意事項相關的常見問題。​​ 

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

過渡性照護服務技術協助資源​​   

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).​​ 

風險分層、細分及分層 (RSST) 及科學諮詢委員會 (SciAC) 成員​​ 

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) 策略成果​​ 

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:​​ 

  • 分享與 LHJs 合作為 2023 年 DHCS PHM 策略交付項目制定的共享目標/SMART 目標的更新；​​  
  • Share how they are meaningfully participating on LHJs’ CHAs and CHIPs, including bright spots and challenges;​​  
  • 分享 14 項行為健康目標的最新進展；以及​​  
  • 證明已完成 NCQA PHM 策略（包括年度 NCQA 人群評估），並提供自上次提交給 DHCS 以來的更新。​​  

會員聯絡及人口統計資料 (MCDI) 倡議策略文件草稿​​ 

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.​​ 

人口需求評估概念文件​​ 

2023 年 5 月 8 日，加州衛生護理服務部（DHCS）發布了一份概念文件，描述其對受管理照護計劃（MCP）必須完成的重新構想人口需求評估 (PNA) 願景。 DHCS 擬定了修改的 PNA，可促進與當地衛生部門和其他社區利益相關者更好的聯繫，更強大的社區參與，以及對成員健康和社會需求和偏好以及他們居住的社區的更深入了解。 這種方法旨在促進更好地定位資源和干預措施，以支持 Medi-Cal 成員的改善健康成果。 DHCS 熱衷於與利益相關者進行這個願景，並通過書面意見和/或參與即將到來的公眾論壇和諮詢小組來鼓勵對概念文件的反饋。 DHCS 將接受公眾對概念文件的意見，直至 2023 年 6 月 2 日。反饋應提交至 PHMSection@dhcs.ca.gov，主題為「PNA 概念文件的評論」。​​ 

最終人口健康管理策略和路線圖​​ 

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 資訊公告​​ 

PHMD 資訊通知 (IN) 是 DHCS 發給管理式保健計劃 (MCP) 和利害關係人的官方通訊，提供人口健康管理 (PHM) 計劃的重要更新、指導方針和資源。自 2024 年 11 月起，DHCS 將在 DHCS 網站上公佈所有新發佈的 PHMD IN，以方便 MCP 和利害關係人存取。​​  

PHMD IN# 26.001：PHM KPI 技術規格更新 2026 年 4 月​​ 

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

PHMD IN#: 25.002 -2025年PHM策略成果提交說明​​ 

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​​ 

關鍵文件​​ 

資訊網路研討會​​ 

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 網絡研討會：封閉循環推薦實施指南​​ 

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.​​ 

電子醫學​​  網路研討會：​​  支持加州醫療補助健康保健計劃成員提供Long-Term Services and Supports ( LTSS ) 需要經歷護理過渡​​ 

8 月 21 日，星期三，DHCS 舉行了一場網絡研討會，關於改善具有 LTSS 需要的會員在他們經歷護理過渡過渡期時提供的服務和支持。 當成員從一個護理場所或地點轉移到另一個地方時，例如從醫院出院到熟練的護理設施（SNF）或從 SNF 轉移到家庭或社區基礎的環境時，就會發生護理過渡。 根據 CalAIM PHM 計劃，管理護理計劃（MCP）負責提供過渡性護理服務，以確保成員從出院計劃過程開始，到過渡過渡，直到成功連接到所有需要的服務和支持為止，都獲得支持。 鑑於 Medi-Cal 的 LTSS 人口提供服務的多樣性和複雜性，利益相關者已要求技術協助，以確保成功轉換到最低限制的護理層級。 雖然所有感興趣的人都可以報名，但這次活動將對 MCP 和負責為有 LTSS 需要的成員護理管理負責的醫療保健設施工作人員特別有益。​​ 

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 所有來者網絡研討會：更新過渡性護理服務（TCS）政策​​ 

DHCS 發布新的過渡性護理服務技術援助資源​​  用於 LTSS 轉換的 TCS TA 資源。​​ 
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 網絡研討會：實施過渡性護理服務的新興實踐​​ 

2023 年 1 月 19 日，DHCS 舉辦了一場全面對 PHM 計劃下的 PHM 過渡性護理服務（CalAIM 的基石）進行了一個全面來訪的網絡研討會。​​ 

過渡性護理服務支援從一個環境或照護程度過渡到另一個環境或等級（例如從醫院出院到家）的個人，以促進護理的持續性並限制服務中斷。 網絡研討會包括討論 2023 年為高風險成員實施過渡性護理服務的新興實踐的小組討論，並概述了最新要求，包括分階段實施時間表。​​  

PHM 服務所有來者網路研討會​​ 

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.​​ 

會議及材料​​ 

卡拉伊姆人口健康管理諮詢小組​​ 

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.​​ 

卡拉伊姆人口健康管理諮詢小組會議信息​​ 

過去的會議和材料​​ 

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 諮詢小組第 13 次會議 -2024 年2 月
簡報幻燈片
錄音
主要觀點
文字稿
聊天記錄
PHM 諮詢小組第 12 次會議 -2023 年 12 月
簡報幻燈片
錄音
主要觀點
文字稿
聊天記錄​​ 

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諮詢小組第9次會議 – 2023年4月
簡報


錄音 主要內容 文字
稿{ 聊天記錄
PHM諮詢小組第8次會議 – 2023年 2月
簡報 記錄{ cph0



簡報記錄​​ 

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

PHM諮詢小組第六次會議 – 2022年10月



演示文稿
錄音 內容{ cph0} 文字稿 聊天記錄
諮詢小組第五次會議 – 2022
年 9月

演示文稿
演示
文稿​​ 

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​​ 

其他資源​​ 

下面列出了其他資源，其中包含有關人口健康管理的關鍵信息。​​ 

媒體卡連接​​ 
人口健康管理概覽​​ 
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.​​ 

問題和評論​​ 

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