Addressing Critical Health Needs: Partnership HealthPlan of California Strategic Response to the 2024 Population Needs Assessment

Business Brief: Addressing Critical Needs in Population Health

Partnership’s membership remained relatively stable in 2023. The member redetermination process, resulting from the winding down of the COVID-19 Public Health emergency, caused some small fluctuations. At the close of 2023, Partnership served approximately 660,800 members throughout 14 counties.

In 2024, Partnership will no longer contract with Kaiser Permanente, will fully operationalize its 10-county expansion, and the Medi-Cal redetermination process will continue.

Partnership’s membership is expected to continue to fluctuate as a result. The 2024 Population Needs Assessment draws from a broad range of data sources to identify member needs along with the overall community conditions where members live.

Executive Summary

The 2024 Population Needs Assessment (PNA) conducted by the Partnership HealthPlan of California highlights significant gaps in healthcare access, economic stability, neighborhood conditions, and social support across its 14-county service area. This brief outlines the critical needs identified and the strategic responses planned to address these issues, ensuring improved health outcomes and equity for all members.

Identified Needs and Strategic Responses

1. Healthcare Access and Quality

Identified Needs:

  • Provider Shortages: Insufficient access to primary care, dental, specialty care, mental/behavioral health, and substance use care providers.
  • Transportation Challenges: Particularly in rural areas, long distances and lack of transportation options hinder access to care.

Strategic Responses:

  • Provider Recruitment and Retention Initiatives:
    • Launching a Provider Recruitment Program to attract healthcare professionals to underserved areas with new incentives, including sign-on bonuses.
    • Implementing a Provider Retention Initiative (PRI) Pilot to incentivize primary care clinicians for long-term service, preserving institutional knowledge and clinical leadership.
    • Telehealth Expansion: Increasing the use of telemedicine to enhance access to behavioral health services, particularly in remote regions.
2. Economic Stability

Identified Needs:

  • High Poverty and Unemployment Rates: Prevalent in rural and frontier regions.
  • Severe Housing Problems: Overcrowding, high housing costs, and inadequate facilities affect many households.

Strategic Responses:

  • Leveraging State Funds:
    • Utilizing initiatives like CalAIM, Community Supports, and the Homeless and Housing Incentive Program (HHIP) to address housing instability.
    • Offering scholarships to local Community Health Worker (CHW) programs to create employment opportunities and enhance the healthcare workforce.
3. Neighborhood and Built Environment

Identified Needs:

  • Limited Access to Healthy Foods: Particularly in rural areas, contributing to poor nutrition and related health issues.
  • High Rates of Physical Inactivity: Linked to chronic health conditions in several counties.

Strategic Responses:

  • Food and Nutrition Programs:
    • Partnering with local agencies to improve access to healthy foods and provide nutrition education.
    • Conducting outreach to promote healthy eating habits and reduce food insecurity.
  • Physical Activity Promotion: Implementing community-based programs to encourage physical activity and healthy lifestyles.
4. Social and Community Support

Identified Needs:

  • High Rates of Adverse Childhood Experiences (ACEs): Leading to long-term negative health outcomes.
  • Substance Use and Smoking: High prevalence of tobacco use and substance abuse, including among adolescents.

Strategic Responses:

  • ACE Prevention and Support Programs: Developing initiatives in collaboration with schools and community organizations to address ACEs and provide support.
  • Substance Use Prevention Campaigns:
    • Conducting educational interventions to reduce tobacco use and prevent substance abuse among adolescents and adults.
    • Promoting smoke-free environments through community outreach and education.

Conclusion

The Partnership HealthPlan of California is committed to addressing the critical needs identified in the 2024 PNA through comprehensive and targeted initiatives. By enhancing healthcare access, addressing social determinants of health, improving neighborhood conditions, and strengthening community support, the organization aims to foster equitable health outcomes and ensure a higher quality of life for all its members.

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Archived Population Needs Assessments

​Community Health Assessments and Community Health Improvement Plan

Partnership participates in the Community Health Assessments (CHA) (sometimes called a CHNA) and Community Health Improvement Plan (CHIP) processes conducted by the local health jurisdiction in each of our 24 counties. This collaboration enhances Partnership’s ability to identify needs and assets within our members’ communities, and strengthens our relationships with community partners.

Below you will find CHAs and CHIPs for each Partnership county in addition to how Partnership participated with the county.

Butte County

Partnership staff participated in a review of the key findings and top 6 health needs identified in the CHA. Butte County released their CHA in December 2023. Click here to view the report.

Modoc County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Modoc County released their CHNA in January 2024. Click here to view the report.

Napa County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Napa County released their CHA in December 2023. Click here to view the report.

Shasta County

Partnership staff participated in a review of the key findings and priority areas identified in the CHIP process. Partnership and Shasta County co-developed a SMART goal focusing on increasing child well visits, aligned with DCHS’s Bold Goals 50×2025 initiative. Shasta County released their CHIP in June 2024. Click here to view the report.

Sonoma County

Partnership staff participated in a review of the county’s approach to their assessment and improvement plan, discussed the county’s 4 priority areas, and gathered ideas for a tentative shared goal with the county. Sonoma County released their combined CHA/CHIP report in December 2023. Click here to view the report.

Yuba County

Partnership staff participated in a review of CHIP health priority areas, and a discussion around how Partnership can help the county going forward. Yuba County released their CHIP in December 2023. Click here to view the report.

ROI Forecasting Calculator for Quality Initiatives

The ROI Forecasting Calculator is an excellent tool for any organization looking to improve quality while keeping costs under control. It can help identify where to make investments in quality, how to prioritize proposed initiatives, and how to demonstrate the financial benefits of investing in quality initiatives. By demonstrating potential cost savings, this tool can also help organizations identify potential areas where they can reduce costs while maintaining or improving quality.

As healthcare costs continue to rise, there is an increasing need to find ways to improve quality while keeping expenses under control. The ROI Forecasting Calculator for Quality Initiatives is a web-based tool that is designed to help state Medicaid agencies, health plans, and other stakeholders assess and demonstrate the cost-savings potential of efforts to improve quality.

The ROI Calculator is an easy-to-use tool that walks users through a step-by-step process to develop ROI forecasts for proposed quality initiatives. Users are asked to enter a variety of assumptions, including target population characteristics, program costs, and expected changes in healthcare utilization. By using these assumptions, the ROI Calculator can help determine where to make investments in quality and how to target proposed initiatives for maximum financial impact.

One of the most significant benefits of the ROI Forecasting Calculator is that it can create a financial case to policymakers for obtaining the resources needed to make those investments in the first place. By demonstrating the financial impacts of investments in quality beyond their upfront costs, the calculator can help policymakers understand the long-term benefits of investing in quality initiatives.

The ROI Forecasting Calculator is an excellent tool for any organization looking to improve quality while keeping costs under control. It can help identify where to make investments in quality, how to prioritize proposed initiatives, and how to demonstrate the financial benefits of investing in quality initiatives. By demonstrating potential cost savings, this tool can also help organizations identify potential areas where they can reduce costs while maintaining or improving quality.

In addition to helping organizations make informed decisions about quality initiatives, the ROI Forecasting Calculator can also improve collaboration between stakeholders. By providing a clear picture of the financial benefits of proposed quality initiatives, the calculator can help stakeholders understand each other’s perspectives and work together to make informed decisions.

Overall, the ROI Forecasting Calculator is an essential tool for any organization looking to improve quality while keeping costs under control. By providing a clear picture of the financial benefits of proposed quality initiatives, this tool can help organizations make informed decisions, collaborate effectively, and ultimately improve the quality of care for patients.

If you’re interested in learning more about the ROI Forecasting Calculator, you can visit CHCSROI.org to access the tool and start forecasting potential savings. Don’t wait; start using this powerful tool to improve quality and control costs today!

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs

The document outlines 47 electronic clinical quality measures (eCQMs) for Eligible Professionals/Clinicians for the 2021 performance period. It categorizes various measures based on quality domains, including effective clinical care, community health, and patient safety, while indicating eligibility for telehealth in select measures.

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs
Total number of EP/EC eCQMs: 47

Measure NameCMS eCQM IDQuality DomainNQF IDMIPS Quality IDMeaningful Measure AreaTelehealth Eligible*
Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS161v9Effective Clinical Care0104e107Prevention, Treatment, and Management of Mental HealthYes
Anti-depressant Medication ManagementCMS128v9Effective Clinical CareNot Applicable009Prevention, Treatment, and Management of Mental HealthYes
Appropriate Testing for PharyngitisCMS146v9Efficiency and Cost ReductionNot Applicable066Appropriate Use of HealthcareYes
Appropriate Treatment for Upper Respiratory Infection (URI)CMS154v9Efficiency and Cost ReductionNot Applicable065Appropriate Use of HealthcareYes
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureCMS249v3Efficiency and Cost Reduction3475e472Appropriate Use of HealthcareYes
Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapyCMS645v4Effective Clinical CareNot Applicable462Management of Chronic ConditionsYes
Breast Cancer ScreeningCMS125v9Effective Clinical CareNot Applicable112Preventive CareYes
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryCMS133v9Effective Clinical Care0565e191Management of Chronic ConditionsNo
Cervical Cancer ScreeningCMS124v9Effective Clinical CareNot Applicable309Preventive CareYes
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS177v9Patient Safety1365e382Prevention, Treatment, and Management of Mental HealthYes
Childhood Immunization StatusCMS117v9Community/Population HealthNot Applicable240Preventive CareYes
Children Who Have Dental Decay or CavitiesCMS75v9Community/Population HealthNot Applicable378Preventive CareNo
Chlamydia Screening for WomenCMS153v9Community/Population HealthNot Applicable310Preventive CareYes
Closing the Referral Loop: Receipt of Specialist ReportCMS50v9Communication and Care CoordinationNot Applicable374Transfer of Health Information and InteroperabilityYes
Colorectal Cancer ScreeningCMS130v9Effective Clinical CareNot Applicable113Preventive CareYes
Controlling High Blood PressureCMS165v9Effective Clinical CareNot Applicable236Management of Chronic ConditionsYes
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)CMS145v9Effective Clinical Care0070e007Management of Chronic ConditionsYes
Dementia: Cognitive AssessmentCMS149v9Effective Clinical Care2872e281Prevention, Treatment, and Management of Mental HealthYes
Depression Remission at Twelve MonthsCMS159v9Effective Clinical Care0710e370Prevention, Treatment, and Management of Mental HealthYes
Diabetes: Eye ExamCMS131v9Effective Clinical CareNot Applicable117Management of Chronic ConditionsYes
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)CMS122v9Effective Clinical CareNot Applicable001Management of Chronic ConditionsYes
Diabetes: Medical Attention for NephropathyCMS134v9Effective Clinical CareNot Applicable119Management of Chronic ConditionsYes
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareCMS142v9Communication and Care CoordinationNot Applicable019Transfer of Health Information and InteroperabilityNo
Documentation of Current Medications in the Medical RecordCMS68v10Patient Safety0419e130Medication ManagementYes
Falls: Screening for Future Fall RiskCMS139v9Patient SafetyNot Applicable318Preventable Healthcare HarmYes
Follow-Up Care for Children Prescribed ADHD Medication (ADD)CMS136v10Effective Clinical CareNot Applicable366Prevention, Treatment, and Management of Mental HealthYes
Functional Status Assessment for Total Hip ReplacementCMS56v9Person and Caregiver-Centered Experience and OutcomesNot Applicable376Functional OutcomesYes
Functional Status Assessment for Total Knee ReplacementCMS66v9Person and Caregiver-Centered Experience and OutcomesNot Applicable375Functional OutcomesYes
Functional Status Assessments for Congestive Heart FailureCMS90v10Person and Caregiver-Centered Experience and OutcomesNot Applicable377Functional OutcomesYes
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)CMS135v9Effective Clinical Care0081e005Management of Chronic ConditionsYes
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)CMS144v9Effective Clinical Care0083e008Management of Chronic ConditionsYes
HIV ScreeningCMS349v3Community/Population HealthNot Applicable475Preventive CareYes
Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentCMS137v9Effective Clinical CareNot Applicable305Prevention and Treatment of Opioid and Substance Use DisordersYes
Oncology: Medical and Radiation – Pain Intensity QuantifiedCMS157v9Person and Caregiver-Centered Experience and Outcomes0384e143Management of Chronic ConditionsYes
Pneumococcal Vaccination Status for Older AdultsCMS127v9Community/Population HealthNot Applicable111Preventive CareYes
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanCMS69v9Community/Population HealthNot Applicable128Preventive CareNo
Preventive Care and Screening: Influenza ImmunizationCMS147v10Community/Population Health0041e110Preventive CareYes
Preventive Care and Screening: Screening for Depression and Follow-Up PlanCMS2v10Community/Population Health0418e134Prevention, Treatment, and Management of Mental HealthYes
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedCMS22v9Community/Population HealthNot Applicable317Preventive CareNo
Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCMS138v9Community/Population Health0028e226Prevention and Treatment of Opioid and Substance Use DisordersYes
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistsCMS74v10Effective Clinical CareNot Applicable379Preventive CareYes
Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationCMS143v9Effective Clinical Care0086e012Management of Chronic ConditionsNo
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsCMS129v10Efficiency and Cost Reduction0389e102Appropriate Use of HealthcareNo
Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseCMS347v4Effective Clinical CareNot Applicable438Management of Chronic ConditionsYes
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiaCMS771v2Person and Caregiver-Centered Experience and OutcomesNot Applicable476Functional OutcomesNo
Use of High-Risk Medications in Older AdultsCMS156v9Patient SafetyNot Applicable238Medication ManagementYes
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsCMS155v9Community/Population HealthNot Applicable239Preventive CareYes

Carenodes Behavioral Health Case Management

ETHOS AND PROGRAM DESIGN

The central premise of the Carenodes Behavioral Health Case Management (BHCM) Program is to promote collaboration between all treating providers, ensuring coordination between medical care and behavioral health care. Once members are identified, Behavioral Health Care Managers outreach / consult with our community partners in medical and behavioral health practice settings. Our program supports the treatment planning needs of providers with respect to behavioral health services and often provides consultation/ suggestions for modifications in current care. This coordination is performed through various avenues including

  • Notification letters to physicians informing them that their patients are engaged with the program,
  • Telephonic outreach calls,
  • Opportunity/option for physician peer-to-peer consultation when needed.

The essence of behavioral health management is ensuring that we direct our members to the right services at the right time.

Our triage and tracking processes include specialized support during service level transitions, such as a discharge from inpatient to outpatient follow-up treatment to ensure that members are attending follow up appointments with community providers within 7 days of hospital discharge. In addition, we utilize a readmission risk algorithm, which identifies members most at risk for readmission to inpatient hospital care. Specialty services are also offered to members diagnosed with eating disorders, maternal mental health issues, families of children and adolescents with a recent inpatient psychiatric stay, and members referred from community providers affiliated with Enhanced Personal Health Care. Also, consenting members engaged in medical care management programs with a positive PHQ2 depression screen or any other BH condition impeding the member’s ability to manage their medical condition are routed to BH for intervention.

Clinical Team/Patient/Family Engagement

Our clinicians work with the member and their family to:

  • Understand the options available for behavioral health treatment, utilize insurance benefits for the lowest possible out of pocket cost, and decrease unnecessary health care expenditures
  • Advocate for the coordination of all care, both medical and behavioral health
  • Educate on symptoms and condition management to prevent future inpatient hospitalization stays
  • Discuss and identify barriers to treatment compliance and offer resources and support to overcome them
  • Improve overall health outcomes for improved quality of life