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PHM
Population Health Management
Identifying who needs what, when — using risk stratification, predictive analytics, and targeted outreach to keep entire populations healthier and out of the hospital.
How it works
From population insight to one-on-one action — closing care gaps before they become crises.
01
Risk Stratification
Continuous, multi-factor risk scoring across clinical, behavioral, pharmacy, utilization, and SDOH data.
02
Care Gap Identification
Real-time identification of overdue preventive care, chronic disease monitoring, and medication adherence gaps.
03
Targeted Outreach
Multichannel, multilingual outreach — phone, text, in-person — sequenced by risk and member preference.
04
Chronic Disease Management
Standardized, evidence-based protocols for diabetes, hypertension, CHF, COPD, asthma, and behavioral health.
05
Preventive Care & Screenings
Workflows that drive cancer screenings, immunizations, well-child visits, and prenatal care across the panel.
06
Quality Measure Performance
Operations built around HEDIS, MCAS, and DHCS quality measures — with feedback loops to the care team.
07
Health Equity
Stratified outcomes reporting and targeted interventions to close documented disparities.
Proven results
The challenge — and the impact
Statewide data from the California Department of Health Care Services (DHCS), Medi-Cal, and CalAIM.
15M+
Medi-Cal members whose care plans rely on population health management
Source · California DHCS
ReadPHM Strategy
DHCS has a statewide Population Health Management strategy under CalAIM
Source · DHCS CalAIM Population Health Management
ReadUp to 30%
Of avoidable ER visits and admissions are addressable through PHM interventions
Source · Industry analyses (NCQA, IHI)
ReadHow we overcome it
What Atlas Health Group does about it
Each challenge above is paired with the concrete way our care model addresses it on the ground.
01
Analytics + boots on the ground
We pair risk stratification and gap identification with bilingual, community-based outreach — so insights actually convert into closed gaps.
02
Built for CalAIM PHM
Our model is aligned with DHCS's CalAIM Population Health Management framework — wellness, prevention, chronic, complex, and palliative care across the life course.
03
Health equity in the workflow
Stratified outcomes, targeted interventions, and multilingual outreach designed to close disparities — not just report them.
Who it's for
Does any of this sound like you or someone you know?
Population Health Management is designed for the situations below. If even one fits you or someone you love, you likely qualify at no cost through your Medi-Cal plan.
01
Health plans managing Medi-Cal panels at scale
02
Members with chronic conditions in need of proactive management
03
Rising-risk members not yet in ECM
04
Members overdue for preventive screenings or immunizations
05
Populations with documented health disparities
06
Plan quality and population health leaders
07
Provider groups working under value-based contracts
08
ACOs and IPAs participating in CalAIM
What's included
Benefits
Tangible support you can count on from day one — fully covered by your Medi-Cal plan.
Risk stratification across the panel
Members are continuously stratified by clinical, behavioral, and social risk — so the right level of intervention finds the right people at the right time.
Proactive outreach & gap closure
Outreach teams close care gaps — overdue screenings, missed follow-ups, lapsed medications — before they become emergencies.
Chronic disease registries
Active registries for diabetes, hypertension, CHF, COPD, asthma, and behavioral health drive standardized, evidence-based management at scale.
Quality measure performance
Targeted work on HEDIS, MCAS, and DHCS quality measures — translating data into the screenings, immunizations, and follow-ups that move the metrics.
Predictive analytics & rising-risk identification
Models flag members whose risk is climbing — so care intensifies before a crisis, not after one.
Health-equity stratification
Outcomes stratified by language, race/ethnicity, geography, and SDOH so disparities are seen, named, and closed.
Ready to get started?
Become a member online in minutes, or call us and a specialist will walk you through it — at no cost when covered by Medi-Cal.