Abstract

This article details the processes and findings of a 3-year demonstration project implementing population health management and the Patient-Centered Medical Home (PCMH) model in 3 community health centers in Alameda County, California. The article provides a first look at the PCMH Continuum, a tool for aiding staff in conceptualizing and implementing complex organizational change. Findings of the project evaluation also are shared, comprising a road map for other organizations looking to implement population health management, panel management, and PCMH. The article reflects on lessons learned and best practices from the demonstration project.

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