Health Centers take a Population Health Management Approach to Care Delivery

October 26th, 2020 | News


As health care increasingly moves towards value-based care, community health centers are actively making changes to how they deliver care to patients and their communities. There is growing recognition that leveraging data to identify and address medical, behavioral, and social needs through a population health management approach is a promising way forward in the path toward higher value care.

In an effort to improve the health and well-being of more than 750,000 Californians, the Center for Care Innovations (CCI) and Blue Shield of California Foundation launched the Population Heath Learning Network in March 2018. PHLN brought together safety net primary care organizations to strengthen and advance their population health management strategies. As the PHLN evaluation partner, JSI assessed participants’ progress in strengthening their population health capabilities, the impact of population health changes made, and the value of technical assistance delivered through the PHLN.

We also developed case studies to highlight innovative strategies that hold the potential to move the needle in a clinic’s population health management journey. The case studies highlight how community health centers use population health management to identify and respond to social needs during the COVID-19 pandemic, improve colorectal screening rates, and better track and monitor behavioral health data.

Highlights from the Case Studies:

How The Los Angeles LGBT Center Championed Population Health to Maximize Colorectal Cancer Screening

“We’re more organized in regard to how we’re looking at clinical care, but more importantly, we’re more successful at managing the community that we serve.” — Claudia Alvarez, Director of Performance Improvement

How Axis Community Health Improved Patient Care by Tracking Behavioral Health Data and Quality Outcomes

The Axis team

“This project has helped us get our foot in the door and open up from there. There’s so much potential now in terms of what we can do. This was our first project using Epic. The PHLN team created a new landscape, so sky’s the limit now!” – Amit Pabla, Chief Quality and Transformation Officer

The COVID-19 Pandemic Has Altered Population Health Management, Creating New Opportunities

A member of staff running a COVID information booth

“In medicine, formal tracking and evaluation come naturally to us around hypertension and diabetes, and this project showed that the same rigor can be used for social needs. This framework lends itself to social needs and can be done effectively with data driven, formal, goal-setting work.” – Barbara Rubino, LADHS

Learn more about the Evaluation of a Population Health Learning Network for the Center for Care Innovations or connect with us directly.

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