California Health Care Improvement Projects (CHIPs)

Ako Jacinto presents his CHIP

California Health Care Improvement Projects (CHIPs) are designed by CHCF Health Care Leadership Program participants with the goal of addressing meaningful challenges or opportunities in health care. 

Browse CHIPs to leverage the work of CHCF alumni and find opportunities to collaborate in order to improve health for Californians.

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Healing the Streets: Integrated, Person-centered, Street-based Care for People Experiencing Homelessness and Severe Mental Illness in Santa Cruz County

Shelly Barker

CalAIM and recent Whole Person Care pilot programs are redesigning how care is offered to people with complex needs in the MediCal system. Housing First models have demonstrated the importance of housing for client well-being, stability, and health outcomes, yet most communities lack adequate temporary and permanent housing options. Efforts thus far have failed to demonstrate compelling outcomes due to a combination of the small sample size and the complexity inherent in interventions for people who are unhoused and often have severe mental illness with co-occurring substance use disorder. The Healing the Streets Program (HTS) set out to test an integrated, person-centered, street-based care model that is not based on offering housing. As a society, we tend to “treasure what we measure;” HTS designed the program uniquely focused on articulating and addressing clients’ goals.

The HTS team of Case Managers, Peers, and a Nurse Practitioner began targeted street-based outreach with an existing physical health street medicine team in February 2022 and started enrolling clients in April. HTS staff utilize motivational interviewing and a “circle chart” depicting potential areas of need (hygiene, food assistance, housing navigation, mental health, etc.) to elicit the client’s goals and begin prioritizing them.

October 18, 2022
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It takes a village – promoting health equity domestically and globally

Takudzwa Shumba, MD, MPH

In recent years, there has been increased focus on health equity, galvanized by events such as Black Lives Matter, and increased awareness of the porosity of borders during the COVID19 pandemic. In my role as faculty lead for DEI efforts within Stanford’s Division of Primary Care and Population Health (PCPH) as well as faculty lead for the division’s global health partnership in western Kenya, I realized that many of the challenges to health equity globally are at play domestically. Our division’s overarching goal is to create a culture of medicine that embraces belonging and mutual respect. My main curricular tasks were to create a DEI curriculum for faculty and staff in our division; as well as to create a curriculum for rotating Kenyan students to Stanford that ensured reciprocal change. I will present the Kenyan student elective curriculum creation to illustrate the complexities and challenges in creating this shared culture, and to highlight the numerous stakeholders involved.

October 18, 2022
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GAIN Project (GAmified INcentives-Based Treatment): Digital Rewards-Based Treatment for Justice-involved Dually Diagnosed Clients

Fumi Mitsuishi, MD, MS

In 2020, there were 700 overdose deaths in San Francisco, which was more than double the number of COVID deaths. Though the proximal cause of death is Fentanyl, 60% of those who died were using methamphetamines, which means that many of those deaths may have been prevented by targeting stimulant use. UCSF Citywide serves nearly 2000 people annually with serious mental illness (SMI), homelessness, and institutionalization (long-term locked psychiatric hospitalization and incarceration). Over the last ten years, we have noted a steady rise in methamphetamine use and associated adverse outcomes in our client population, including worsened psychotic symptoms, increased likelihood of arrests or recidivism, increased social challenges (such as houselessness), and increased use of acute psychiatric services. Unlike many substance-use disorders, methamphetamine-use disorder (MUD) lacks an effective medication-based intervention. The only treatment with a clear evidence base is contingency management (CM). However, this treatment has not been widely used because of two challenges, (1) it has only been used experimentally because it financially rewards clients for reducing substance use, which brings up concerns about cost, sustainability, and diversion of funds, and (2) it is administratively complex to implement. The first challenge has been answered. The fact that California will launch a state-wide CM pilot through CalAIM and there is interest at the federal level to make CM reimbursable through public insurance indicates that CM will become a mainstream treatment. T A digital solution can answer the second challenge by using an app that would make CM more scalable by reducing the heavy administrative burden. We have obtained $1M philanthropic funding to develop an app to provide contingency management to our justice-involved clients who struggle with mental health challenges and substance use disorder. This project aims to (1) provide CM to reduce stimulant use, (2) increase digital literacy and access to aim for “digital belonging” for those at the margins of society, (3) support overall recovery goals through gamification and rewards, and (4) clarify implementation steps necessary to provide CM to this highly marginalized population successfully.

October 18, 2022
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Team Based Care to Reduce Burnout

Anjali Mahoney, MD, MPH

Clinicians at Keck Medicine of USC are burned out due to the COVID 19 pandemic, competing demands on their time and insufficient support to achieve work life balance. This project was designed to establish a team-based care program at Keck Medicine of USC to reduce clinician and staff burnout in the Family Medicine Department. Burnout affects over 50% of physicians and nurses and leads to reduced access to care due to sick calls, reduced patient safety and lower quality of care. Clinicians are more likely to leave practice due to burnout and depersonalize patients which leads to poor interactions. Keck Medicine was facing a high turnover rate for clinicians and nurses (close to 20%). The goal was to create a team-based care program by December 2022 to reduce clinician burnout and improve engagement. In our health system clinicians spend an inordinate amount of “pajama time” doing charts, paperwork and answering messages. Charts are late, patient messages are unanswered, and prescriptions are not refilled in a timely manner due to burnout. Patient complaints have gone up and patient satisfaction scores decreased. To achieve Team Based care at Keck Medicine the goals were identify the steps, get leadership buy in, launch a prototype. Develop a plan to build the necessary infrastructure, learn the roles of the team members and train to work at the top of the skill sets, understand the barriers to overcome them.

October 18, 2022
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A Digital Safety Net Engaging Patients through Automation to Drive Outcomes

Barbara Rubino, MD

“Lost to follow up” is a too-common refrain in the ambulatory healthcare setting and is particularly problematic in primary care, whose focus and value lie in an ongoing, longitudinal relationship with the patient. Academic primary care practices often care for socially or medically complex patients and may lose 25-45% of patients to follow-up. Patients, PCP teams, and the system are all impacted differently by this challenge. Patients can experience a decline in their health status and poor outcomes if they cannot access care in ways and at times that are convenient for them. PCPs can get burnt out and frustrated trying and failing to keep track of their patients. Our systems then see the cost of care increase.

Working for a primary care practice embedded in a healthcare technology company has opened my eyes to data and technology tools. An added focus on engagement can bolster the traditional healthcare focus on outcomes. With these tools, we’ve created a digital backstop and started to mitigate the “lost to follow up” problem by building a system that continuously engages patients. Notably, we began with a much more specific focus – to improve patent outcomes on key quality metrics (such as rates of cancer screening and diabetes eye exams) but uncovered and are successfully addressing this broader opportunity.

We built a digital safety net – a dynamic data model which keeps track of all empaneled patients and deploys automated patient- and team-facing communication at clinically appropriate intervals. This model is always updating and drives patients back to care. Our goals were: 1) to engage patients with their primary care team at clinically appropriate intervals, 2) to prompt patients to follow through with their care plans, and 3) to promote the healthcare team to reach out to patients when they become overdue for care, to take away the cognitive load of manually tracking patient registries that often burden the care team.

October 18, 2022
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Decreasing Iron Deficiency Anemia in Pregnancy

Nathana Lurvey, MD, FACOG

am Director of Women’s Health for Eisner Health, an FQHC which provides physician and midwife care to 2000 birthing people annually at two safety net hospitals in Los Angeles. Local, statewide, and national data all show significant health disparities around maternal morbidity. The majority of maternal morbidity is secondary to the need for transfusion. Women who present to labor and delivery anemic are more likely to need transfusion. Internal data at the two facilities where Eisner delivers infants showed that one quarter of women at one facility and nearly one half of women at the other presented anemic to labor and delivery. As nearly all of our patients had received prenatal care, it was clear that the usual approach of referral to WIC for high iron food, use of oral iron pills, and standard nutritional information during prenatal care was not sufficiently effective. There needed to be an option to escalate care to include IV iron infusion during pregnancy. Although this is not novel, the existing workflow required referral to hematology prior to receipt of transfusion. Very few women were actually referred.

My CHIP required me to obtain funding for and implement a short cycle care management approach focused on women identified as anemic during pregnancy, with the initial goal of ensuring that all women presented in labor with a hematocrit of 33% or more. As part of the revised workflow, there would be follow up every two weeks in the second half of pregnancy for women identified as anemic and direct referral to the hospital for iron infusion if oral intake did not reverse the anemia.

Achieving this required coordination between outpatient clinic staff (health educators, midwives, physicians, registered dieticians, pharmacy, and laboratory) and inpatient resources (nursing, pharmacy, midwives and physicians).

Since one of the birthing facilities for Eisner is part of the CommonSpirit Health system, I had the benefit of being able to leverage the resources of CommonSpirit Health’s Women and Infants Clinical Institute, a national advisory group for the 67 birthing facilities that are part of CommonSpirit Health. I brought forward the data from Eisner and California Hospital to the national meeting in Phoenix in January 2020. A sister facility in Phoenix was also focused on similar work. Based on our advocacy, the creation of a standard workflow and a small trial was authorized at the CommonSpirit Health maternity line meeting. Eisner Health and California Hospital were to be one of three demonstration sites. COVID however delayed everything with actual project initiation on patients being delayed until March of 2022.

October 18, 2022
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Envisioning a post-pandemic Digital Behavioral Health Department

Magdalena Serrano, MCW, LCSW

Rather than seeing COVID-19 as an insurmountable obstacle, I, along with my team at Community Health Centers of the Central Coast (CHCCC), Inc., viewed it as an opportunity to accelerate the pace of innovation. To better meet the needs of the community, the CHC Behavioral Health and Psychiatry Departments are committed to moving beyond brick-and-mortar clinics to a ‘click and mortar’ clinic in the sky, the Cielo Center for Integrated Health. Like many health centers CHCCC quickly shifted to virtual care not long after the pandemic emerged. However, not until the Omicron wave of Covid-19 in January 2021 did I commit to transitioning the behavioral health department to a fully digital service model. The entire landscape of healthcare changed in 2020. I realized I had to pivot our strategy and re-design our clinical structure. I began to design a CHIP in late January with the project aim of increasing access to behavioral health services by creating an organized, fully digital continuity-of-care system for our patients. This system includes a network of remote behavioral health clinicians to ensure patients are provided with outreach and engagement, wellness coaching, counseling, and psychiatry services. An integrated team of physicians, nurses, counselors, health educators, psychiatrists, and care coordinators collaboratively engages, triages and coordinates care through a cloud-based EHR system. This model creates a digital doorway for patients, allowing them to access services anywhere in the community. Moreover, this hybrid model of in-person and remote services bridges the digital divide and promotes health equity by ensuring patients have choices along the continuum of care.

October 18, 2022
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