In 2023, CenCal Health began two multi-year Performance Improvement Projects (PIP) to be completed in 2026. The Non-Clinical PIP aims to improve the percentage of provider notifications for members with substance use disorders (SUD) and/or serious mental health (SMH) diagnoses following or within 7 days of an emergency department (ED) visit. The Clinical PIP focuses on improving Well-Child Visits in the First 15 Months—Six or More Well-Child Visits (W30–6) for CenCal Health’s Black and African population; however, CenCal found that addressing the Hispanic/Latino population would significantly support the need to decrease the disparity among other racial/ethnic counterparts.
These efforts support the goal of improving member health outcomes, functional status, and overall quality of life through addressing medical, behavioral, and social drivers of health. The annual submission of this project is underway and will be submitted to the Department of Health Care Services (DHCS) in August 2025. This submission includes current efforts and collaborations both within CenCal Health and with partnering community organizations and providers. The submission will also identify the efficacy of the implemented interventions, comparing the baseline period of calendar year 2023 to the remeasurement period of 2024.
Non-Clinical PIP
Current efforts underway to improve follow-up rates after an ED visit for either substance abuse and/or mental health disorders include a comprehensive Provider Portal report, which can be accessed through individual provider portal accounts and displays members recently seen in the ED and the due date for a timely follow-up. Additional efforts include provider collaborations to identify challenges and providing support and available resources to improve location-specific rates. Lastly, Population Health is working collaboratively with the Behavioral Health Department to develop a member-facing education piece to create a multifaceted intervention approach to this measure.
Best Practices:
- Establish a workflow to check the new Provider Portal report daily to identify patients needing follow-up.
- Upon member ED use identification, schedule follow-up appointments within 7 days.
- Develop a tracking method for patients due or past due for follow-up after discharge.
Clinical PIP
Current efforts underway to improve the rate of Well-Child Visits in the First 15 Months—Six or More Well-Child Visits (W30–6) for the Hispanic/Latino population are focused on partnering with community-based organizations to increase community understanding of the importance of these visits. In collaboration with the County of Santa Barbara’s Lompoc Health Care Center, a presentation was given to the Family Service Agency to equip advocates with information and resources that can be shared with the families they serve. Additionally, a program is in development that equips Community Health Workers/Promotoras with outreach to CenCal Health families who may be past due for Well-Child Visits.
Best Practices:
- Utilize the Well-Baby Opportunity Report, located on the Provider Portal, to capture members at risk of falling behind on visits.
- Adhere to the scheduling recommendations of the Bright Futures/ American Academy of Pediatrics Periodicity Schedule.
- Combine Well-Child Visits with other appointments, when appropriate.
For further questions, please reach out to the Population Health team at: populationhealth@cencalhealth.org