What's New at CCI? Expanding community clinic power

Welcome to Whats New at CCI? — the bi-weekly newsletter from the Center for Care Innovations (CCI) where you can take in the latest news, updates, and ideas on health care x innovation x resilience and more! Get notified of future editions , delivered straight to you on your LinkedIn feed.

In this issue, we celebrate the end of our first year in a statewide partnership?to elevate health equity for patients throughout California — and we can't wait to share the update with you.

Celebrating Year One of the Population Health Management Initiative:?Collaborating with Partners to Elevate Health Equity

A team from the Center for Care Innovations (CCI) was honored to join its partners in the Central Valley city of Fresno to help lead a recent regional learning session for community health center participants in a statewide health partnership to improve health equity in California. With support and community resource-sharing from the Central Valley Health Network and other partners, the participants focused on health-related social needs, medical assistant retention, and support for care coordination.

“It was a huge success,” said Kristene Cristobal , CCI’s Vice President of Programs, noting the high survey ratings from participants. “People really loved the team time away from clinic to develop new ways to care for their patients.”?The first of four regional learning sessions, it involved coaching and facilitation from CCI and JSI subject matter experts, as well as interactive learning activities.

The gathering was followed by a second regional learning session with Aliados Health in Santa Rosa this August. Both sessions were part of the?Population Health Management Initiative , or PHMI, for which CCI is a technical assistance partner. PHMI may be one of the most innovative collaborations ever to involve health care delivery in the Golden State. The mammoth partnership is designed to improve health care for low-income patients and to take medicine beyond the four walls of a clinic.?

PHMI is a California collaboration of the California Department of Health Care Services , Kaiser Permanente , and community health centers (CHCs). It supports a cohort of 32 CHCs, which serve 1.1 million people (about the population size of Montana) across the state, to help them improve their capabilities to manage population health and align with Medi-Cal policy and payment reform initiatives – part of a long-term plan to erase health care disparities in the state.

?? Check Out These Great Resources from the Population Health Management Initiative!

The resources generated by PHMI are available to all health care employees and health centers. Here are some your team might find especially helpful:

• The?Population Health Management Capabilities Assessment Tool , which is designed for primary care practices or CHCs.
• The?Population Health Implementation Guide Series , which?includes step-by-step guidance for primary care practices and CHCs that want to strengthen population health management. Here are some of our favorites:

?? The?Care Teams and Workforce Guide , which helps leaders evaluate team care roles, identify gaps, and develop a workplace plan of action.

?? The?Data Quality and Reporting Guide , which helps expand clinics’ capacity to monitor PHMI/HEDIS quality measures and improve quality of care.

There are also specific guides for populations of focus, including?the Children Guide ,?Pregnant People Guide , ?Adults with Preventive Care Needs Guide ,?Adults Living With Chronic Conditions Guide , and?People with Behavioral Conditions Guide .

?? To stay informed,?sign up for Population Health Management Initiative newsletter .

CCI is part of the Initiative’s Practice Transformation Team, along with JSI, the Institute for Healthcare Improvement ( IHI ), AllianceChicago , and UCSF’s UCSF | Center for Excellence in Primary Care . We are working with the 32 CHCs to promote equity and strengthen capabilities for population health management that improves health outcomes.

The CHCs are working on care for specific populations, including adult preventive health and management, child health, maternal health, and behavioral health care.?As part of their work, each CHC has selected a specific population of focus — Children, Pregnant People, Adults with Preventive Care Needs, Adults Living with Chronic Conditions, and People with Behavioral Health Conditions — and core quality measures tailored to the care their providers deliver and the people they serve.

Besides holding online webinars and helping plan and convene the regional learning sessions for PHMI, CCI and its partners work to link community clinics with health equity coaches, implementation guides and other resources. "The regional learning sessions are designed to be responsive to the challenges health centers are facing. We have learnt that one of the greatest benefits is for clinics to learn directly from each other," said CCI President Sofi Bergkvist .

Among these challenges is how to improve patient engagement, something that many clinics have noted that they can't do all on their own.?Collaboration with other organizations, like community-based organizations, often requires data sharing. This is something many clinics are focusing on: How to improve the use of data to understand the population’s needs, and then partner with the most relevant organizations in the community to engage with patients in new ways.?

PHMI also opens up new ways to partner with community groups to improve their patients' social health. “All the clinics are so interested in meeting the social needs of their patients,” said Cristobal, noting this includes not only food, respite care, peer support, and secure housing but a stronger sense of community and connection. "It's a process of continuous learning."

"We’re dedicated to supporting CHCs to adopt effective population health management strategies,” said Alvaro Fuentes , Senior Director, Consulting, Kaiser Permanente & PHMI. “We recognize that CHCs are crucial in delivering high-quality and culturally appropriate care for California’s most vulnerable populations – and we’re proud to work with CHCs and all of our practice transformation partners to implement tailored population health management interventions.”

???? We look forward to seeing you at the Summit! #SNIS2024

The?Safety Net Innovation Summit ?(#SNIS2024) returns next week to?gather social impact transformers like you?who are serving historically underinvested and marginalized communities — providers, community leaders, entrepreneurs, technologists, funders, payers, and more.?We’ll be focusing on?Inclusive Innovation: Navigating Trust and Health Equity in the Era of AI. This summit is a pivotal event dedicated to exploring how artificial intelligence can be harnessed to advance health equity, with an emphasis on building trust within the health care safety net.

...Already have your ticket??Check your inbox for important attendee reminders and instructions as we gear up for the Summit!

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