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 an Enhanced Care Management (ECM) partner, 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 California Primary Care
Medi-Cal’s CalAIM initiative is 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
Our team acts as an extension of your practice, helping you identify the HEDIS and performance metrics that matter most. We provide additional resources and support so your practice can close gaps in care, improve outcomes, and strengthen performance.
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
- Asthma Medication Ratio
Behavioral Health
- Follow-Up After Hospitalization
- Depression Screening and Follow-Up
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 ECM standards
Getting Started: How It Works
01
Onboarding
Receive onboarding materials and authorize collaboration so HHN can begin partnering with your practice to support patient needs effective.
02
Identify High-Need Members
Identify high-need patients requiring additional support and securely share their information with HHN to coordinate timely care as needed.
03
HHN Engages Patients
Our team engages patients, schedules appointments, and removes common barriers so your practice can improve attendance and care outcomes.
04
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.
By continuing, you agree to our Website and SMS and Privacy Policy.