Federally Qualified Health Centers (FQHCs) serve as lifelines for underserved populations, but face systemic barriers in adopting Population Health Management (PHM) including payment models that prioritize volume over value, workforce shortages, and fragmented data systems. In 2022, California launched the Population Health Management Initiative (PHMI), a partnership between Kaiser Permanente, 32 FQHCs, the California Department of Health Care Services, and regional primary care associations to address these challenges and strengthen PHM capacity through technical assistance aligned with Medicaid reforms.

PHMI provides practice transformation coaching and tools to build core PHM competencies while addressing social determinants of health (SDOH) such as housing and food insecurities. Between March and August 2024, we conducted one-hour interviews with 84 staff across 29 FQHCs to explore implementation barriers and facilitators, analyzing data using thematic analysis. Early findings reveal: 1) technical assistance enhanced FQHCs capabilities in key areas of PHM, including data quality and reporting, care teams, and empanelment; 2) leadership engagement was essential for culture change; and 3) effective communication and coaching models strengthened clinical and care team workflows. Clinics leveraging these resources (e.g., technical assistance, coaching) improved population health management despite challenges like staff turnover and competing clinical demands.

These findings demonstrate that PHM adoption in FQHCs requires both technical capacity-building and organizational transformation. PHMI offers a replicable framework for improving FQHCs’ PHM capacities while working within resource constraints. These findings have national implications for supporting FQHCs in learning PHM, which can improve quality while preparing for value-based care and addressing SDOH.