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Population Health Management (PHM) Programs

Population Health Management (PHM) is a collection of services that work together to ensure you get the services you need at a schedule that works best for you. CenCal Health has a PHM system to ensure all services are suited to your culture and language. CenCal offers several programs to our members, including:

Community Support Programs

Community Supports are services that can help you beyond your basic health needs. You may qualify for support with housing, personal care, getting food, and more. These services can help you stay healthy at no cost to you. 

CenCal Health offers a variety of Community Support Programs such as: 

  • Recuperative Care Program (RCP) 
  • Medically Tailored Meals/Medically Supportive Food Program 
  • Housing Transition Navigation Services 
  • Housing Deposits 
  • Housing Tenancy and Sustaining Services 
  • Personal Care and Home Maker services  

If you qualify for Community Supports Programs, you may enroll in these programs by calling CenCal Health’s Member Services Department at 1-877-814-1861 (TTY/TDD 1-833-556-2560 or 711), Monday – Friday, 8 a.m. – 5 p.m. or the Community Supports Department at 805- 562-1698 

To learn more about Community Support Programs, please visit CenCal Health CalAIM Webpage. 

Wellness and Prevention Program

CenCal Health provides a Wellness and Prevention Program to all members in order to: 

  • Focus on preventing illness and injury 
  • Promote healthy behaviors 
  • Help Members identify and manage their health risks 
  • Reduce risk factors 

         CenCal Health’s Wellness and Prevention Program includes the following major components: 

        Services for Members Less than 21 Years of Age  

        • Initial Health Appointment (IHA)  
        • Children’s Preventive Services  
        • Immunizations  
        • Blood Lead Screens  
        • EPSDT Services  
        • Behavioral Health Treatment (BHT) Services   
        • Local Education Agency (LEA) Services  
        • Rapid Whole Genome Sequencing 

        Services for Adult Members

        • Initial Health Appointment (IHA) for Adult Ages 21 and over
        • Adult Preventive Services
        • Immunizations

        Services for Pregnant and Postpartum Members  

        • Risk Assessment 
        • Referral to Specialists 

          Wellness and Prevention Campaigns  

          CenCal Health Wellness and Prevention campaigns all include:  

          • Health education about the service you or your child is due for, why it is important, and how often it should be done, and how to access the preventive service.  
          • The ability to follow up with a Health Educator for more support and information.  
          • Access to an online health education library with information, tools, and resources for a healthy lifestyle.  
            To learn more about CenCal Health’s Wellness and Prevention campaigns, please call 1-800-421-2560 ext. 3126 or send a message to the Health Education team through your online 
            Member Account

                Self-Management Tools

                CenCal Health’s self-management tools help Members determine risk factors, provide guidance on health issues, and recommend ways to improve health or maintain low risk. Topics covered include but are not limited to:

                • CenCal Health’s self-management tools help Members determine risk factors, provide guidance on health issues, and recommend ways to improve health or maintain low risk. Topics covered include but are not limited to:   
                • Healthy weight ( Mass Index) maintenance  
                • Smoking and tobacco use cessation  
                • Encouraging physical activity  
                • Healthy eating  
                • Managing stress  
                • Avoiding at-risk drinking  
                • Identifying depressive symptoms  
                  To view the library of self-management tools, visit CenCal Health’s public website 
                  www.cencalhealth.org/health-and-wellness/self-management-tools   

                            Population Needs Assessment

                            CenCal Health annually assesses its population to identify health disparities or gaps in services. The annual Population Needs Assessment (PNA) evaluates data sources to assess the characteristics and needs, including social determinants of health, of its member population. To view the most recent Population Needs Assessment, please visit: https://www.cencalhealth.org/explore-cencal-health/population-needs-assessment/

                            Health Appraisals

                            CenCal Health administers health appraisals annually for adults and children, called the Adult and Pediatric Health Survey Tools (HST). Results from the HSTs initiate Case Management and Disease Management outreach and follow-up, as appropriate. To check if you have a Health Appraisal due, visit your online Member Account. 

                             

                            Disease Management Program

                            CenCal Health’s Disease Management services ensure that your care is coordinated between your providers, including your: 

                            • Primary Care Practitioner (PCP) 
                            • CenCal Health staff 
                            • Specialist provider 

                                The programs and services can address the following health conditions: 

                                • Asthma 
                                • Cardiovascular Disease 
                                • Diabetes 
                                • Depression 
                                • Maternal mental health 

                                        Disease Management Programs and Services connect with other community programs to help you: Improve self-management skills. 

                                        • Improve consistency to treatment plans. 
                                        • Decrease symptoms associated with your health condition. 
                                        • Prevent future problems. 
                                        • Prevent development of other conditions related to your health condition. 

                                        If you qualify for Disease Management Program support, you may enroll in these programs by: 

                                        • Reaching out to Member Services via the Member Portal 
                                        • Calling CenCal Health’s Member Services Department at 1-877-814-1861 (TTY/TDD 1-833-556-2560 or 711), Monday – Friday, 8 a.m. – 5 p.m. or the Community Supports Department at 805- 562-1698 

                                          Self-Management Tools

                                          CenCal Health offers self-management tools on several topics to help you navigate health challenges and thrive. Self-management tools will help you: 

                                          • Determine risk factors. 
                                          • Provide guidance on health issues. 
                                          • Recommend ways to improve health. 
                                          • Reduce risk or maintain low risk. 

                                                Shared Decision-Making Aids

                                                CenCal Health offers tools and resources on several topics for members to make informed decisions about their health with the help of their providers so the patient can choose what is right for them. Decision making aids will help you: 

                                                • Identify needs 
                                                • Plan steps 
                                                • Track your progress 
                                                • Advocate at your doctor appointments 

                                                      To access the Shared Decision Making Aids, visit the CenCal Health Make a Health Decision Webpage. 

                                                      Health Education Library

                                                      CenCal Health offers a health education library on our website with access to various health topics. This library contains several articles, tools, and videos on chronic disease management. Check it out! 

                                                      To learn more, visit the CenCal Health Health & Wellness Webpage. 

                                                      PHM for Children 

                                                      CenCal Health encourages all members under 21 to attend preventive visits either your PCP and complete all recommended screenings and exams. 

                                                      CenCal Health coordinates health and social services for children between different settings. This ensures that children and their families can access medically, emotionally, and socially necessary services in a timely manner. 

                                                      Whole Child Model Program

                                                      CenCal Health offers a pediatric care management program  included in the Whole Child Model (WCM) for the California Children’s Services (CCS). The WCM provides  utilization and case management services for children and youth with special health care needs. 

                                                      CCS assists children 20 years of age or younger with serious medical conditions requiring specialty medical care or physical rehabilitative services. The WCM will address both CCS and non-CCS conditions to address the whole-person approach to care. 

                                                      The CCS county program will decide if your child qualifies for CCS services. If your child qualifies for CCS services, a dedicated care coordination team in CenCal Health is available to assist with health care needs. 

                                                      To learn more, visit the CenCal Health California Children’s Services Webpage. 

                                                       

                                                      Care Management Services  

                                                       CenCal Health offers a range of care management and coordination services designed to provide personalized support to meet the diverse needs of our members. These services include: 

                                                      • Complex Care Management (CCM) 
                                                      • Basic Care Management 
                                                      • Transitional Care Services (TCS) 
                                                      • Enhanced Care Management (ECM) 
                                                      • Other care coordination activities 

                                                              It was developed to help you use health care services and gain access to state programs, community-based resources, and long-term services and support. Access to those services will allow you to keep your independence at home, live in the least restrictive environment, and be the best version of yourself. 

                                                              You might be eligible if you have: 

                                                              • Complex medical conditions or psychosocial needs 
                                                              • A specific diagnosis that puts you at risk 
                                                              • Care coordination or care transition assistance needs 

                                                                To learn more about Care Management Programs, please visit the CenCal Health Case Management Webpage.  

                                                                If you qualify for Care Management Program support, you may enroll in these programs by: 

                                                                • Reaching out to Member Services via the Member Portal 
                                                                • Calling CenCal Health Member Services Department at 1-877-814-1861 (TTY/TDD 1-833-556-2560 or 711), Monday – Friday, 8 a.m. – 5 p.m. or the Community Supports Department at   805- 562-1698 

                                                                  Interpreter Services

                                                                  As a CenCal Health Member, you can request interpreter services for your appointment. To access translation during your health appointments, contact Member Services at 1-877-814-1861 (TTY/TDD 1-833-556-2560 or 711), Monday – Friday, 8 a.m. – 5 p.m. 

                                                                  As always, don’t hesitate to Ping me for questions for this update! Thank you!