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Population Health Programs

Community Health Partnership’s Population Health Programs are quality improvement and research initiatives coordinated with our community health centers to positively affect population health. Through our Population Health Programs, clinicians can evaluate the health status of patients with chronic conditions as a group.

Quality Improvement Program (QI)

Through the Quality Improvement (QI) Program, our member community health center network participates in regional and state-wide efforts to improve the quality of care provided to patients of community health centers. The program aims to improve processes, systems, and access to care by implementing best practices and standards that have a positive impact on the health outcomes of the patients.

Current projects initiatives are: Aligning Quality Improvement in California Clinics for Meaningful Use (AQICC-MU) and Preventing Heart Attack and Stroke Everyday (PHASE).

The purpose of the QI Program is to work collaboratively to monitor, evaluate, and improve the services and patient care provided by community health center (CHC) members. The goal for quality improvement is to resolve identified issues, ensure optimum care of CHC patients, and positively influence the health of patients.


  • To support CHCs efforts to treat, manage and improve health outcomes of patients with chronic conditions by providing training on evidence-based clinical practice guidelines, technical assistance support on information technology and quality improvement projects, and patient education materials to health centers actively participating in the Quality Improvement program.

  • To resolve common quality issues affecting delivery of care and services to CHC patients through a system of problem assessment, identification, study, corrective action, monitoring, evaluation, and assessment that is timely and relevant.

  • To effectively utilize Health Information Technology to gather and analyze data, and to generate reports that can be used to track progress towards quality improvement goals.

For more information or questions about the Quality Improvement Program or its projects, please contact Director of Clinical Services, Elena Alcala, MPH

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Aligning Quality Improvement in California Clinics for Meaningful Use

In collaboration with California HealthCare foundation, the California Primary Care Association, and clinic consortia throughout California, Community Health Partnership is in the process of implementing a statewide performance improvement project, Aligning Quality Improvement in California Clinics for Meaningful Use (also known as AQICC).

The purpose of the project is to help community clinics and health centers in California prepare for the meaningful use of electronic health records (EHR) to improve clinical outcomes and operational efficiencies in order to ultimately improve the health outcomes of patients and communities throughout the state.


  • Assist community health centers in their goal to achieve meaningful use of EHR employing existing learning community models.

  • Optimize the use of electronic chronic disease registries.

  • Collect, report, and use validated data for clinical and operational improvements.

  • Utilize state level data to affect policy change.

Activities for Health Center Medical Directors

  • Participate in learning sessions – session topics will include various aspects of achieving meaningful use of EHR.

  • Report validated clinical data (HbA1c and LDL) to be included in the statewide project.

  • Report appropriate operational data (measures TBD) to be included in the statewide project. 

  • Include regular progress reports on AQICC/Meaningful Use in report to CHC Board of Directors.

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Preventing Heart Attack and Stroke Everyday (PHASE)

The Preventing Heart Attack and Stroke Everyday (PHASE) project aims to improve the health status of adults living with diabetes that are at high-risk for heart attacks and strokes.PHASEis an evidence-based, risk-reduction strategy to prevent heart attacks and strokes in adult diabetics over the age of 55.  PHASE was initially launched by Kaiser Permanente in 2003 to address the high rate of heart attacks and strokes among its diabetic members at highest risk.

The effective implementation of PHASE and its impact on reversing the trend of cardiovascular mortality was the impetus to translate this practice to the broader community, particularly among the most vulnerable and underserved. Beginning in 2006, grants were awarded by Kaiser Permanente Community Benefit to implement PHASE in safety-net clinics.  PHASE pilot clinics are Ravenswood Family Health Center and Gardner Family Health Network. 

The goal of the PHASE implementation program is to improve the standard of care for patients at risk for heart attacks and strokes.  PHASE focuses on ensuring that high-risk patients take medications proven to reduce cardiac and stroke events.  These drug classes-antithrombotics (asprin), statins, ace-inhibitors and beta blockers-are demonstrated in the scientific literature to improve blood pressure, LDL levels and blood glucose levels.  Clinics enroll high-risk patients with diabetes that are between the ages of 55 and 80, and provide them with three, and in some cases four proven preventive medications that help manage cholesterol, hypertension, and heart disease. PHASE also focuses on educating patients about smoking cessation, physical activity, healthy eating, and weight management. Through this program, patients receive follow-up for up to two years to ensure they continue with their care and for the purpose of collecting and reporting outcome measures.

Promote PHASE as the standard of care for diabetic patients between the ages of 55 and 80 at the community health center by: 

  • Establishing Project Infrastructure for enrollment of PHASE patients.

  • Developing  and implementing a  quality improvement plan for PHASE

  • Developing and implementing the technology infrastructure required to track PHASE health outcome and tracking measures

  • Evaluating systems and processes, and make changes as appropriate


  • ID high-risk patients (diabetes over the ages of 55 and 80)

  • Prescribe medications to help manage cholesterol, hypertension, and heart disease.

  • Provide patients with education on how to make lifestyle changes for smoking cessation, physical activity, healthy eating, and weight management. 

  • Ensure high risk patients receive recommended medications and aggressive risk factor management to help slow the disease process and prevent future cardiac and cerebral vascular events.  

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Research Project iCARE: Innovative Care Approaches through Research and Education

Community Health Partnership has partnered with the UCLA School of Public Health, the California Primary Care Association (CPCA) to conduct research focused on two innovative care approaches in community clinics and health centers throughout Santa Clara, San Mateo, and San Francisco counties.  This research partnership will build on the clinics’ ongoing work focused on improving delivery systems for patients with chronic conditions. 

Project iCARE, funded by the Agency of Health Research and Quality, will provide a unique opportunity to compare the effectiveness of two team-based strategies increasingly used by community clinics and health centers for managing diabetes care.

Research collaborators will compare the effectiveness of:

  • Office-based patient panel management by medical assistances

  • Community based care management by community health workers on improving the quality of diabetes care and patient self-care behaviors

Uncontrolled chronic illness negatively affects the US healthcare system’s ability to meet the growing needs for all who will seek primary health care with the implementation of health care reform. By identifying and disseminating financially feasible approaches for delivering chronic illness care, Project iCare, has potential to address the growing need for comprehensive primary care.

For more information, please contact:
Elena Alcala, MPH, Director of Quality Improvement- Community Health Partnership

Valerie Sheehan, MPH, Deputy Director of Development - California Primary Care Association - (916) 440-8170 x1118

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