California Health Care Improvement Projects (CHIPs)

Developing an Advanced Practitioner Training Academy

California is in a critical primary care shortage. In 2018 an estimated 45% of Californians had insufficient access to a primary care provider. This lack of access leads to increased morbidity, mortality and cost of care. This shortage is reflected in my own organization Neighborhood Health Care, an FQHC in San Diego. To effectively care for all of our assigned patients, we needed to expand our current workforce by 20%.

In 2020 we attempted to recruit clinicians, but numerous positions remained vacant for months, with no physician or experienced advanced practitioner applicants. There were, however, numerous new-graduate advanced practitioner applicants. These candidates were enthusiastic and mission-oriented but lacked experience and suffered disruptions in their training due to COVID.

In my CHIP I developed a training program to prepare recently graduated advanced practitioners to care for our complex patient population. The Advanced Practitioner Training Academy (APTA) focuses on providing high quality, evidence-based primary care, an excellent patient experience and easy access to appointments. Training consisted of precepted continuity clinics, specialty rotations and didactic sessions.

Addressing the Sexually Transmitted Diseases (STDs) Epidemic in Yuba County

Sexually transmitted diseases (STDs) have increased exponentially in the past several years nationally and statewide. Yuba County as a small rural county in northern California has one of the highest rates of congenital syphilis with a crude rate of greater than 112.9 congenital syphilis cases per 100,000 live births. From 2017 to 2022, the rate of syphilis increased from 17 to 84.1 cases per 100,000.

In California, incarcerated individuals are among the individuals most impacted by STDs. This CHIP project aimed to implement an STDs opt-out testing program for all inmates coming into the Yuba County Jail – a facility with an average jail population in the 180s during the COVID-19 pandemic but is now back to its pre-pandemic level of mid-300s to low 400s. The STDs opt-out testing program was paired with public health staffing of part-time social workers and a nurse to provide social services linkages and medical/behavioral health linkages, respectively.

The planning and implementation of this CHIP project as a public health officer during the height of the COVID-19 pandemic was extremely difficult. This was made more challenging when the proposal to contract with WellPath as the jail medical provider to provide the STDs opt-out testing and treatment was denied by the CA Department of Public Health (CDPH) because WellPath is a for-profit company. Through the project lead’s persistence in providing justification for why WellPath was chosen, CDPH ultimately approved the contract with WellPath and the project successfully started in September 2022.

Unionize the Physicians at Alameda Health System (AHS)

Today, nearly 70% of healthcare providers are employed by large corporate entities. While there are benefits to large healthcare systems, providers in these organizations are feeling disengaged and disempowered due to the inability to effectively advocate for their patients or themselves. This lack of voice contributes to provider burnout, directly affecting the quality of care being delivered and physician attrition.

At AHS, we saw an annual 11% attrition rate of quality physicians compared to the national average of 4-6%. The cost of replacing one physician ranges anywhere between $250K to $1M. In addition, we areconcerned about physician shortages, it is predicted that California will have the highest shortage ofhealthcare providers by 2030. After talking to numerous providers, I discovered that the main reasonsfor low morale were the inability to effectively advocate for patients, below market compensation andbenefits, and lack of influence on the workplace environment. My goal was to develop a retention planthat incorporated these factors to retain high quality physicians in a safety net system. Myunconventional but not unprecedented approach was to unionize the physicians at AHS.