Helping Primary Care Practices Improve HEDIS & Quality Metric Scores
Heritage Health Network (HHN) partners with primary care practices to ease the operational and regulatory demands of value-based care.
By working with a case management partner like HHN your practice can improve patient outcomes, streamline care coordination, and achieve key quality measures—all without increasing staff or operational workload.
The New Reality for Primary Care Practices
Medi-Cal and MediCaid program new program requirements are transforming how care is measured and reimbursed. Practices now must:
- Coordinate care across medical, behavioral, and social needs
- Engage patients who are hard to reach or have multiple conditions
- Document measurable outcomes for value-based payment programs
Meeting these standards internally often requires new staff, workflows, and technology, which can be costly and resource-intensive.
We Can Ease Your Practice’s Burden
Some of the key HEDIS and performance measures we’ve helped primary care practices improve include:
Preventive Care
- Childhood Immunization Status
- Adolescent Immunizations
- Well-Child Visits
- Cervical Cancer Screening
- Breast Cancer Screening
Chronic Disease Management
- Controlling High Blood Pressure
- Diabetes Control
- Lifestyle and Diet Coaching
- Medication Adherence
Behavioral Health
- Rapid BH care coordination
- Closed-loop referrals & follow-through
- Whole-person stabilization
- Actionable updates to PCPs
- Reduced ED and crisis utilization
Care Coordination & Maternal Health
- Transitions of Care (TOC) 7-day post-discharge
- Emergency Department (ED) utilization ↓ avoidable visits
- Prenatal & Postpartum Care (PPC)
- Community Health Assessment and Patient Satisfaction (CHAPS)
HHN Can Provide the Additional Resources You Need - At No Cost
Meeting these standards internally can be costly. By partnering with HHN, your practice can leverage without additional staffing or operational burden.
| Role | Cost if Internal | HHN Cost |
|---|---|---|
| Behavioral Health Case Manager | $87,098 | $0 |
| Social Worker | $69,931 | $0 |
| Case Manager | $67,426 | $0 |
| RN (Supervisor) | $128,131 | $0 |
| Total | $352,586 | $0 |
How HHN Supports Your Practice
- Care coordination between PCPs, specialists, behavioral-health, and social-service providers
- Transitions of care within seven days of hospital or ER discharge
- Chronic-disease & behavioral-health support for diabetes, heart failure, depression, and SUD
- Patient engagement through home visits, calls, and field outreach
- Social-needs like housing, food, transportation, and other supports
- Documentation shared securely with the PCP and care team per MCP and DHCS
Getting Started: How It Works
Onboarding
Receive onboarding materials and authorize collaboration so HHN can begin partnering with your practice to support patient needs effective.
Identify High-Need Members
Identify high-need patients requiring additional support and securely share their information with HHN to coordinate timely care as needed.
HHN Engages Patients
Our team engages patients, schedules appointments, and removes common barriers so your practice can improve attendance and care outcomes.
HHN Tracks Outcomes
Quarterly reports monitor outcomes, surface care gaps, and give your practice clear insights to strengthen HEDIS performance and value-based results.
Connect with us to see how we can help your team close care gaps and improve patient outcomes.
Reach out today to start the conversation.
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