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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
If you qualify, Community Supports may help you with nutrition and housing related needs. These services are optional. They do not replace benefits that you already get under CenCal Health.
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

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 https://wwwqa.cencalhealth.org/members/calaim/

Wellness and Prevention Programs

CenCal Health provides Wellness and Prevention Programs to all members to help you improve your physical and mental health.

CenCal Health Wellness and Prevention programs 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.
  • The ability to follow up with a Health Educator for more support and information.
  • Access to online health education library with information, tools, and resources for a healthy lifestyles.

CenCal Health’s current Wellness and Prevention programs:

Stay Healthy: Adults – Mailings sent to all adult members who are overdue for important preventive care such as:

  • Check-ups with Primary Care Practitioner (PCP)
  • Breast cancer screening
  • Colorectal cancer screening
  • Cervical cancer screening
  • Yearly blood pressure check-up

Stay Healthy: Kids–Mailings the parents of all pediatric members who are overdue for screenings/checkups.
Breathing Better –Mailings sent to all members with asthma that provides:

  • Health education about asthma self-management as well as information about the correct use of different medications.
  • An Asthma Action Plan to be completed yearly with your PCP.

Healthy Pregnancy – Offered to all members who are newly pregnant. This health education program includes a targeted mailing that provides:

  • Health education about the importance of timely prenatal visits and information on a healthy pregnancy, including nutrition, dental care, immunizations, mental wellness, physical activity, and more.

Healthy Postpartum – Offered to all members who are newly postpartum, through 12 months postpartum. This health education program includes a targeted mailing which provides:

  • Health education information on the importance of timely postpartum visits, postpartum wellness, nourishment, birth control and more.

“Know More” series – provides health information through short and interactive videos! Each “Know More” program focuses on a different topic to help reduce chance of illness. Current programs within the “Know More” series include:

  • Know More: HPV
  • Know More: STIs
  • Know More: Vaping
  • Additional “Know More” topics are planned for development
Disease Management Programs
CenCal Health’s Disease Management Programs (DMPs) 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.

To access the Self-Management tools webpage, click here

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 webpage, click here

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 https://wwwqa.cencalhealth.org/health-and-wellness/

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 called the Whole Child Model (WCM) for the California Children’s Services (CCS). The WCM provides inclusive services for children and youth with special health care needs.

CCS does not cover all health conditions. CCS covers most health conditions for those who are physically disabled or that need to be treated with medicines, surgery, or rehabilitation (rehab).

CCS county program staff will decide if your child qualifies for CCS services. If your child qualifies to get this type of care, CCS providers working with CenCal Health will assign a personal care coordinator to help coordinate treatment using a care team.
To learn more, visit https://wwwqa.cencalhealth.org/members/ccs/.

Care Management Program
CenCal Health Care Management (CM) program is an inclusive, member-centered program that consists of

  • 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 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
https://wwwqa.cencalhealth.org/members/calaim/

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.