California Health Care Improvement Projects (CHIPs)
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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Beyond the X-waiver: Normalizing MAT Prescribing in Primary Care
Dawnell Moody, DO, MPHIn January 2023 the DEA and SAMSHA announced elimination of the X-waiver as a requirement to prescribe Suboxone (buprenorphine/ naloxone) for opioid use disorder which presented an opportunity to reduce one barrier to treatment, access to X-waivered providers, among patients at a suburban community health center. This project looked at the willingness of primary care providers not previously X-waivered to begin prescribing Suboxone for patients on a stable dose before and after a peer-led training. It further assessed if there was a difference in willingness to prescribe buprenorphine for chronic pain vs opioid use disorder. Prior to the training, 60% of providers indicated they were likely to prescribe buprenorphine for an indication of chronic pain or opioid use disorder and 40% of providers responded they were not likely to prescribe for either indication. After a one-hour peer training and the creation of a reference guide the number of providers likely to prescribe for an indication of chronic pain was 71% while the percentage likely to prescribe for opioid use disorder was 57%. Those not likely to prescribe for chronic pain dropped to 28%, but the number not likely to prescribe for opioid use disorder remained nearly the same at 43%. During the three months between the peer training and data collection one provider began sending Suboxone prescriptions for a patient with opioid use disorder. In the post-training survey, a question was asked about the new DEA license renewal requirement to complete 8 hours of education on substance use disorders which started in June 2023. Out of the two providers who completed the new requirement one felt it increased their willingness to prescribe MAT and one reported it had no effect.
October 25, 2023View/Download PDF
Yes, Your Voice Matters
Sheila Young-Mercado, MDThe City of Compton, California and community of North Long Beach, California continue to experience extraordinary barriers to lifesaving medical care. With the highest rates of maternal mortality, infant mortality, and homicide in Los Angeles County, these areas lack essential lifesaving medical services including, a high-risk hospital-based birthing center, a neonatal intensive care unit, and a level-one trauma center. Furthermore, individuals in these communities suffer higher rates of blindness, amputation, kidney failure, heart attack and stroke, the negative sequelae of chronic medical conditions such as uncontrolled diabetes mellitus and uncontrolled hypertension. It is no wonder, therefore, that the life expectancy in Compton and North Long Beach are 77.1 years and 78.9 years respectively, compared 87.5 years among the “best performing city or community” in Los Angeles County.
Through CHIP interviews, I was connected with a group of individuals who are passionate about improving the access to health care in Compton, California. In the fall of 2022, we created the Compton Health Equity Collaborative. Overall, we believe that with California boasting one of the highest GDP per capita in the US and having the fifth largest economy in the world, there is no reason why we cannot work together to provide Compton and North Long Beach with culturally and linguistically appropriate life-sustaining medical care.
Our overarching goal is to empower community members to be the architects of the way health care is delivered in their communities and to build capacity among community members to provide basic and advance health care services. This is a long-term project where we envision a comprehensive health care center and a corresponding hospital run and staffed by individuals from the community with the lived experiences to meet their friends, family, co-workers, and neighbors' needs.
October 25, 2023View/Download PDF
Trauma Informed Care Transformation and Universal Screening for ACEs/Toxic Stress in a Student Health Setting
Deirdre Logan, MD, MMMMy CHIP project is Trauma Informed Transformation of a Student Health Center and Universal ACEs screening. I am currently an Assistant Professor of Clinical Obstetrics and Gynecology in USC Student Health. Prior to joining USC in 2018, for 10 years I was Chief physician of an Ob/Gyn department in a Federally Qualified Health Center in South Los Angeles. Our service planning area had some of LA County’s highest rates of STIs, Teen pregnancies, Preterm deliveries, Low birth weight babies, and all cause morbidity and mortality rates. Exposure to toxic stress and adverse childhood experiences are higher in racial/ethnic minorities, women, immigrants, LGBQT+ individuals, people with disabilities, those living in poverty, and other historically marginalized groups, and within these groups there is an increased risk of being adversely affected by trauma; our patients represented many of these groups. We universally screened all OB patients for depression with PHQ9s; although a great screening tool, it wasn’t the optimal screen for our patient population.
Many of my current patients, college students, are experiencing high levels of stress; this coupled with histories of ACEs and toxic stress may negatively affect mental health and academic performance. According to SAMHSA, in community samples more than two thirds of people have experienced a traumatic event by age 16; other studies note more than one third of adults in the general population have experienced at least two ACEs. Newer cohorts report more ACEs than older cohorts indicating the incidence of ACEs may be increasing1. Even students without overt signs of stress may have histories of toxic stress. Toxic stress can have significant impact on academic performance, physical, and mental health outcomes, so universal screening of patients can provide opportunities for early interventions to mitigate toxic stress, prevent academic barriers to success, and increase positive health-related outcomes.
I am the Chair of USC Student Health’s Trauma Informed Steering Committee, Co-Chair for the American College of Ob/Gyn’s District IX DEI Committee, a member of ACOG’s National DEI Delegation, USC Department of Family Medicine’s Anti-Racism Task Force, and USC Student Health’s DEI committee. My professional, clinical, and personal experiences have cultivated a perspective that considers the intersections between toxic stress and the lived experiences of persons from marginalized groups. The Trauma Informed Steering committee identified ACEs as a screening tool that could be used with our patient population to assess for toxic stress. The original ACE Study was conducted in the late 1990’s (by Kaiser Permanente and the CDC) among a clinical population of 17,337 middle-class insured adults, 79.4% were white, had a mean age of 56.1 years, and 43% percent had graduated from college. The study identified a set of 10 categories of common, adverse experiences occurring in the first 18 years of life, and confirmed ACEs are highly prevalent and demonstrate a strong dose response relationship with numerous negative health and social consequences in adulthood2 . With a DEI lens and guided by the SAMHSA principle of gender and cultural awareness, we created a hybrid ACEs questionnaire to reflect the diversity of our population and their experiences. Our modified ACEs is 18 questions and is an amalgamation of the original 10 ACEs with additions from the Expanded Philadelphia ACEs and the ACEs IQ (International) to include other items that focus on community ACEs (discrimination, poverty, community violence, foster care, and neighborhood safety).
October 25, 2023View/Download PDF
Maximizing 340B Revenue
Sommer Kaskowitz, DNP, FNP-BCCentral City Community Health Center, Inc. is a federally qualified health center that relies on 340B savings to supplement our care to the uninsured and underinsured communities we serve. Unfortunately, our 340B program has never been optimized to fully realize the full benefits of the program. In 2021, we were experiencing multiple organizational barriers including lack of 340B program awareness among our staff, not capturing savings from providers we refer our patients to, and many missed opportunities that led to potentially millions of dollars being left on the table.
A multipronged program was developed to address these challenges, including a quarterly training program, 340B resources for providers/staff/patients, referral capture, and implementation of an in-house pharmacy. The immediate goal was to increase 340B revenue by at least $1 million and begin referral capture by December 2023.
October 25, 2023View/Download PDF
Implementing CalAIM Community Supports to Create a System of Safe Discharge Options for Challenging Patients from Acute Care Facilities to Decrease Administrative and Denied Days
Dennis Hsieh, MD, JDMedicaid patients remain in acute care settings (acute hospitals, long term acute care hospitals, skilled nursing facilities) because there are no safe, clinically appropriate discharge options. This results in an increased number of administrative or denied days because the patients are no longer clinically acute and are just awaiting placement. Patients who could be in an inpatient bed or in a skilled nursing facility are instead stuck boarding in the emergency department or an inpatient bed. This leads to crowding both in the emergency department and the inpatient setting, which is both bad for the patient and costly for the health care system.
Enhanced Care Management (ECM) and Community Supports (CS), as offered through California Advancing and Innovating Medicaid (CalAIM), can address this problem by increasing the number of safe, clinically appropriate discharge options. The challenge is weaving the discrete benefits and funding streams offered under CalAIM into a system of care that augments the existing discharge options.
This project focuses on the implementation of CalAIM Community Supports by translating CalAIM’s vision into a concrete approach through nontraditional partnerships. The project expands the capacity of existing service providers (personal care services providers, shelters, recuperative care/medical respite, transitional housing, sober living environments, board and cares, assisted living facilities, residential care facilities for the elderly (RCFEs), etc.) through using CalAIM CS to pay for these services and makes them directly accessible to acute care facilities as Medicaid funded discharge options.
October 25, 2023View/Download PDF
Bringing Accompaniment to Inpatient Clinical Spaces: The Creation of a Health Advocate Program for Black Inpatients at UCSF Health
Sujatha Sankaran, MDNationwide, Black patients who are admitted to the hospital experience disparities in pain management, patient communication, length of stay, and readmission rates. This disparity is seen at UCSF Health, where black inpatients have lower patient communication scores, higher lengths of stay in the hospital, and higher readmission rates than the rest of the patient population. In addition, there is limited engagement and input from community members in the care that hospitalized patients receive at UCSF Health.
The aim of this initiative is to improve care for Black inpatients by hiring Black community health workers to act as advocates who accompany Black patients during their health journey. These health advocates improve care for Black patients by elevating the patient voice, helping patients navigate the complex health system, and providing teaching for patients to help them advocate for themselves during hospitalization.
October 25, 2023View/Download PDF
Inpatient University: Empowering seamlessly
Gabriel Ortiz, MD, PhDOften, education of our hospitalized patients occurs in the last few hours of their stay. And there are no standards for how to perform this critical work. This project was inspired by my Spanish-speaking patient, Jose. Jose was re-admitted to our hospital with cirrhosis and volume overload, a new diagnosis that was made just a few months prior to when I cared for him. In exploring what happened, he barely recognized the term “cirrhosis” let alone Lasix and the other medications that were prescribed to control his symptoms. Lots of evidenced-based practices exist for management interventions and clinical care decisions (e.g., goal directed therapy for heart failure or sepsis), but few standards are reinforced around the key education a patient should receive about their clinical diagnoses before they are sent home from the hospital. This project is titled “Inpatient University” as it aims to standardize a patient-centered curriculum to guide the empowerment of our patients. And it aims to make this education and communication as easy and seamless as possible for hospital staff.
There are three key aims for the “Inpatient University” project:
• Standardized education to be delivered to our patients throughout the course of their hospitalization,
• Simple written instructions given to patients at time of discharge, and
• Assurance that instructions on pill bottle labels dispensed from our Discharge Pharmacy are always translated into a patient’s preferred language.
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