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HPSM’s Population Health Management (PHM) Program

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HPSM’s Population Health Management (PHM) Program


HPSM’s Population Health Management (PHM) Program

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HPSM’s Population Health Management (PHM) Program

HPSM’s PHM Program offers four special support programs to help our members stay healthy:

Baby + Me

Promotes timely care and health from the start of pregnancy to birth and beyond. HSPM Medi-Cal members who are pregnant or who recently delivered a baby are eligible for this program. Those who enroll can earn up to $100 in Target GiftCardsTM for going to two appointments!

  • During pregnancy: members who go to a prenatal visit within the first 12 weeks of pregnancy get a $50 Target GiftCardTM
  • After having their baby: members who go to a postpartum visit between one and 12 weeks after having their baby get a $50 Target GiftCard

HPSM’s Health Promotion staff can also connect members to other local resources and services, such as: 

  • Breast pump vendors. Please provide your patients with a prescription so their order can be processed.
  • Local programs for parents and families. These cover a wide range of needs, from nutrition support to parenting classes.
  • Doula services. 
  • And more!

Learn more about Baby + Me, including how to refer eligible members. Members can learn more, join or opt out by calling HPSM’s Health Promotion Unit at 650-616-2165.

Medi-Cal members get doula services at no cost. Doula services include support before, during and after childbirth (including support during miscarriage, stillbirth and abortion). To receive care, members need a recommendation for doula services signed by their physician or other licensed practitioner on their record. To complete a recommendation for a member, you can use this template for a doula recommendation. Learn more about doula services.

The Bullseye Design, Target and Target GiftCards are registered trademarks of Target Brands, Inc. Terms and conditions are applied to Gift Cards. Target is not a participating partner in or sponsor of this offer.

The Diabetes Prevention Program (DPP)

A no-cost, 12-month program for Medi-Cal members that can lower the risk of getting type 2 diabetes. It includes weekly one-hour sessions led by trained Lifestyle Coaches for the first six months and monthly sessions in the last six months. Coaches help participants create plans for eating healthy, exercising more and losing weight. They also provide handouts to help people meet their personal health goals. Plus, program participants get group support. 

The program is for people who:

  • Are 18 years old or over.
  • Are overweight (Body Mass Index ≥ 25 or ≥23 if self-identified as Asian).
  • Are not pregnant.
  • Do not have diabetes (type 1 or 2).
  • Do not have end-stage renal disease (kidney failure). 
  • Meet one of the following: 
    • Have prediabetes. 
    • Have had gestational diabetes in a past pregnancy. 
    • Get a result of high-risk for type 2 diabetes on the CDC Prediabetes Risk Test.

Learn more about the DPP, including how to refer members. Members can learn more, join or opt out by calling HPSM’s Health Promotion Unit at 650-616-2165.

Care Transitions

Helps members who’ve been sent home from the hospital avoid returning to the hospital. Once home, members can be referred to HPSM’s Integrated Care Management Team (ICM) for follow-up. The ICM team assigns the member a Care Manager who:

  • Helps the member develop and follow their care plan. 
  • Connects the member with their primary care provider. 
  • Talks with the family about other care needs. 

Members can learn more, join or opt out by calling HPSM's Integrated Care Management Team at 650-616-2060.

Complex Case Management 

Helps members who have one or more ongoing health conditions get the care they need to reach their health goals. Ongoing health conditions can include diabetes, high blood pressure or asthma. Emotional and social support is also offered through plan providers, partners and local resources. 

HPSM’s Care Managers call eligible members inviting them to join the program. Members can opt in or out at that time. Once a member joins the program, a Care Manager is added to their care team. This Care Manager follows up regularly to: 

  • Identify and prioritize concerns, goals and interventions. 
  • Develop a care plan with the member. 
  • Help secure other support services. 
  • Assist in managing many health issues and needs.

Learn more about Complex Case Management on our website or call the Integrated Care Management Team at 650-616-2060.