The following are projects that our team is currently conducting.

Addressing Contextual Factors in Chronic Disease Management in Minority Older Adults through Photo-based Patient-Clinician Communication

Description: In this project, we aim to develop a patient-centered, communication intervention called Photo+Care to elicit and better integrate contextual factors into clinical care for multiethnic and linguistically diverse older adults who have diabetes and multiple chronic conditions (MCC). The premise of Photo+Care is that a picture is worth a thousand words, meaning that photos can promote efficient information exchange and activate patients to communicate their complex lived experiences. The objectives of this project are to: 1) describe the contextual factors that impact self-management of diabetes and MCC by conducting observations in patients’ homes followed by photo-guided interviews with patients and 2) develop Photo+Care by conducting iterative in-depth interviews with patients, providers, clinic team members and clinic leaders to develop all components of the intervention including how it could be delivered and integrated into the primary care setting.

Funding: 

• National Institutes of Health, National Institute on Minority Health and Health Disparities (K23MD015089), PI: Jih
• National Institutes of Health, National Institute on Aging, UCSF Claude D. Pepper Older Americans Independence Center (P30AG044281), PI: Covinsky (Pilot PI: Jih)
• National Institutes of Health, National Center for Advancing Translational Sciences (KL2TR001870)
• UCSF Hellman Fund

Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE)

Description: This project builds out SMART-on-FHIR patient and clinician-facing apps for the collection and visualization of patient reported outcomes (PROs) for patient self-care and for shared decision making. The patient-facing smartphone app is available in English and Chinese to collect and track questionnaire-based PROs such PROMIS physical function, fatigue, pain and sleep, PHQ-2, GAD-7, health-related social needs and medication adherence. The PRO results are accessible via the clinician-facing BRIDGE data dashboard within the EPIC electronic health record via SMART-on-FHIR. We will conduct a pilot single-arm feasibility and acceptability trial to demonstrate the use of mPROVE in clinical workflows.

Funding: 

• AHRQ U18HS026883, PI: Jih

A Proof-of-Concept Pilot Ride Share Voucher Program to Reduce Transportation Barriers and Primary Care Visit No Shows among Medically Complex Patients

Description: The main goal of this proposal is to implement a ride share voucher proof-of-concept pilot for a subset of patients that have a high no show rate, screen positive for transportation barriers and have medical complexity that require follow up in the UCSF Health Mount Zion Division of General Internal Medicine General Medicine Practice every 2-3 months. This work would provide the proof-of-concept and allow us to assess if the ride share voucher results in increased follow up, reduced no shows and improved patient experience as well as the financial implications of this work for UCSF Health that could make a persuasive case to UCSF Health Primary Care Services administrative leaders to extend this program beyond the proof-of-concept pilot.

Funding: 

• Mount Zion Health Fund 20230807, PI: Jih/Patridge

Identifying and Addressing Health-Related Social Needs in the UCSF General Medicine Practice

Description: Unmet health-related social needs can negatively impact health outcomes and increase health care utilization. Addressing these social needs through an established process and referrals to community resources can help reduce their negative effects. The objectives of this project are to: 1) conduct a needs assessment focused on the unmet health-related social needs of patients receiving primary care at the UCSF DGIM General Medicine Practice and 2) develop a multi-level intervention to address at least one of the most prevalent unmet health-related social needs of our patients.

Funding: 

• Mount Zion Health Fund (P0515824), PI: Jih

Identifying and Assessing Food Insecurity in Older Diverse Primary Care Patients

Description: In this project, we: 1) describe the prevalence of food insecurity and associated clinical characteristics in diverse older adult patients with multiple chronic conditions (MCC) using electronic health records (EHR), 2) assess the utility of PhotoVoice for eliciting patient attitudes and behaviors regarding their food insecurity, and 3) assess the feasibility, acceptability and potential impact of incorporating PhotoVoice as a communication and assessment tool for food insecurity in the primary care setting.

Funding: 

• National Institutes of Health, National Institute on Aging (R03AG050880), PI: Jih