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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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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Leadership through a Staffing Crisis

Manel Silva, MD

Staffing crises have become endemic in healthcare. The costs go far beyond the financials, deeply affecting morale and patient care. Balancing patient needs, staff morale, equity, and future expectations is a challenging skill set. This project will describe a leadership journey through a staffing crisis, and highlight lessons learned.

October 18, 2022
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access to “Nutrition super-powers” in the era of obesity and chronic diseases

Sujana Gunta, MD, MS, FAAP

Chronic diseases (eg: heart disease, stroke, DM, kidney disease, cancer) account for 5 of the top 10 causes of death in our country. Obesity is a well-known risk factor for all these chronic diseases, and we have almost 40% of US adults and 20% of children obese in the US, and the COVID pandemic has only worsened these trends. We currently have outstanding innovations in the field of medicine that focus on medications, delivery methods, and surgeries, yet our communities continue to struggle with chronic disease management and increasing rates of obesity.

It couldn’t be emphasized enough that nutrition plays a major role in the prevention, risk reduction, and management of obesity and chronic diseases. Yet, healthcare models lack focus on it. My work is to highlight the power of nutrition in obesity and chronic disease prevention, risk reduction, and management in a model of integrated care.

The challenge was to create the nutrition-focused model in an FQHC (Federally Qualified Health Clinic) setting, with communities that are uninsured or underinsured, lack access to transportation, have limited means and income, rely on community health clinics for their comprehensive care, and all these barriers further muddled with insurance payment models failing to focus on prevention. The interviews with the stakeholders - patients and their caregivers, clinicians, leads from other departments, and healthcare leaders from other organizations to understand the needs of the community and the success/failures of previous efforts in this arena and community-based organizations - proved to be extremely vital in shaping the direction of this project.

October 18, 2022
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Autism: Breaking the cycle of health disparity in Los Angeles County

Ashley Wiley Johnson, PhD, CCC-SLP

When a child receives an autism diagnosis, the work has just begun. Parents are faced with a myriad of challenges, many of which may persist across the lifespan. Social skill deficits is one of the hallmark features of the disorder. This can impair a baby’s ability to give a social smile, or an adult’s ability to obtain and maintain meaningful employment. Despite it being one of the persistent challenges and a critical area to intervene, many families and care providers, are unaware of treatment approaches focusing on social skill development and how to access or provide these types of services to the client.

In our center, we see each day how Cognitive Behavioral Therapy focusing on pragmatics changes the trajectory of our clients lives and sets them up for a successful and meaningful life as an adult. On the contrary, we see how many of our clients who have an autism diagnosis, are given speech therapy and ABA through insurance, but still struggle due to poor social skills. When asked why their child does not have social skills treatment, many parents respond, “my doctor only told me about ABA”, “I can’t get a hold of the regional centers”, or “I didn’t know this type of treatment exists”.

This CHIP project seeks to demystify access to cognitive behavioral treatment for families in Los Angeles County who have children with Autism. In the fact finding and discovery process, I found the need to add an important element; bringing knowledge about treatment approaches to the primary care providers, so they can best help the client with autism and their family.

October 18, 2022
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