California Will Launch Statewide Medi-Cal Population Health Management Program

California’s Advancing and Innovating Medi-Cal (CalAIM) seeks to transform the Medi-Cal (California Medicaid) delivery system for more than 14 million Californians, adopting a population health approach that prioritizes prevention and care for the whole person and addresses Medi-Cal members. The continuum of care includes physical, behavioral, developmental, dental, and long-term care needs.

As a key part of CalAIM, California’s Department of Health Care Services (DHCS) is launching the Population Health Management (PHM) program in January 2023.1 The PHM program establishes a statewide, standardized, data-driven approach to ensuring that all Medi-Cal managed care members can access services based on their needs and preferences, with the most needy Medi-Cal From wellness and prevention to care management for members. , In conjunction with the PHM program, DHCS is also launching a statewide “PHM Service” solution in July 2023, which will provide access to current and historical data that is currently available separately, and through its statewide standardized risk stratification and segmentation Supports PHM program ( RSS) algorithm, analytics and other functionalities. The PHM service is part of a broader, statewide effort to accelerate and expand health and social service information among health care institutions, government agencies, and social service organizations under California’s Data Exchange Framework (DxF).

An important goal of both the PHM program and PHM service is to address the widening health disparities in the Medi-Cal program for people of color relative to the general population, which have been further exacerbated by the COVID-19 pandemic.

Under PHM, Medi-Cal Managed Care Plans (MCPs) will operate within a common set of baseline expectations while being responsive to individual member needs within local communities. PHM program requirements apply exclusively to MCPs. However, PHM is a statewide effort that interacts with other delivery systems and carved-out services – notably California’s specialty mental health system, which is county-based – and thus is a collaboration between MCPs and other stakeholders as well as members themselves. A meaningful connection is required. ,

Under the new PHM program, DHCS is setting comprehensive requirements for MCPs within each of the four domains of the PHM Framework (see Figure 1 below):

Figure 1: PHM Framework

  • PHM Strategy and Population Need Assessment: Foundational to the success of PHM implementation is a comprehensive data-driven strategy that prioritizes collaboration with community partners. In California today, MCPs are required to measure health disparities and identify the primary health and social needs of their members through a Population Needs Assessment (PNA). Beginning in January 2023, DHCS will improve the PNA process to include greater community engagement and align with other processes such as hospitals’ community health needs assessments and local health departments’ community health improvement plans. The PNA will also support the development of a new annual PHM strategy detailing each component of MCP’s PHM approach, prioritizing strong relationships in the community, and cross-sector efforts to improve health in neighborhoods and communities with poor health outcomes strategies will be included.
  • Collecting Member Information: The PHM program also emphasizes on collecting, sharing and evaluating timely and accurate individual level data to identify efficient and effective opportunities for interventions. DHCS will require each MCP to collect and use a variety of data to administer the PHM program, including data generated within the MCP and externally, including provider referrals, member demographics (e.g., race, ethnicity, , preferred language) including but not limited to. and information from screening and assessments. When the PHM service goes online, it will enhance and consolidate information available outside managed care delivery systems and provider practices for MCPs, including members’ health history, needs, and administrative, medical, behavioral, dental, and social service data There are risks involved in taking advantage of. and other program information from different sources. The PHM service will also use the data to support assessment and screening processes.
  • Understanding Risk: Before the PHM service goes live in July 2023, MCPs are expected to have their own data-driven RSS approaches that consider all information to avoid and reduce bias and prevent health disparities. Once the PHM service goes live, it will use the collected data to support a statewide standardized RSS algorithm and risk stratification process, which will be developed with stakeholder input and a group of national experts. Specifically, the PHM service will use a risk stratification process that assigns all individuals served by Medi-Cal to a risk level (i.e., high, medium-increased, or low) in order to derive information from all Medi-Cal deliveries. Will use standardized criteria for keeping in the system account. MCPs will be required to use PHM service risk levels as a baseline to identify and assess member-level risks and needs and connect members to services as needed. MCPs can use local data sources (i.e., clinical data or zip code level social drivers of health data) or real-time data that can be accessed through these PHMs for the purpose of identifying additional members for further assessment and services. Can complement service outputs.
  • Providing Services and Support: One of the main objectives of PHM is to connect MCP members with the right services at the right time and in the right setting based on their needs and preferences. DHCS will require each MCP to offer the supports and programs that members need and want along the continuum of care, which will include Basic Population Health Management (BPHM) for all members; care management programs, including Enhanced Care Management (ECM) or Complex Care Management (CCM) for high-risk and select moderate-emerging-risk members; and transitional care services for members in care transition (see Figure 2 below). With the PHM service’s analysis and reporting functionality, DHCS will have a better ability to understand population health trends and the efficacy of various PHM interventions, as well as strengthen oversight.

Figure 2: PHM Care Management Continuum

PHM is a journey rather than a destination. Over time, the PHM program will evolve to support greater integration into distribution systems, moving beyond the current requirements for MCPs.

The launch of the PHM program and the deployment of the PHM service are part of a broader change to improve health outcomes that began with CalAIM and is further articulated in DHCS’s comprehensive quality strategy. Through these collective efforts, California is making significant progress in improving whole-person care for Medi-Cal members, reducing health disparities, and making meaningful progress in quality and health outcomes, aiming to combine quality with prevention. and linking health equity efforts.

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