The Office of Population Health (OPH) is committed to the systemic study and evaluation of UCSF Health patient populations and population health management interventions using a learning health system (LHS) approach. The National Academy of Medicine defines a LHS as “one in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care.” OPH collaborates with faculty, staff and trainees at UCSF who share a commitment to a LHS approach.  The OPH LHS team 1) systematically designs and evaluates OPH interventions, 2) produces generalizable knowledgeable that may be disseminated in scholarly products, and 3) balances pragmatism, feasibility, and scientific rigor in OPH’s work and goals.


Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Tailored Outreach (poster)
Snyder A, Wheeler M

The Transitional Care Model: A Randomized Control Trial (poster)
Brinker E, Jones D, Lee N, Snyder A, Wheeler M, Zarkower A

Striving for Equitable Outreach (poster)
Casey J, Compton L, Hoyt A, Lee N, Snyder A, Wheeler M

Diabetes Collaborative Care Launch (poster)
Kuryan C, Clairmont L, Trinh E, Hsiao V, Noya C

Improving Depression Screening Rates in Primary Care: Creation and Integration of a Pre-Appointment Electronic Tool (poster)
Marty Schroeder M, Appelle N, Bauer E, Belay M, Eichelberger J, Slocum J, Brannen J, Coleman S, Connors C, Lynn E, Stead C, Toliver T

A Call to Improve Health by Achieving the Learning Health Care System
Collard HR, Grumbach K

The Transitional Care Model: A Randomized Controlled Trial (poster)
Brinker E, Jones D, Lee N, Snyder A, Wheeler M, Zarkower A

STEDDI: Short Term Emergency Department Discharge Intervention (poster)
French M, Andersen R, Judson TJ, Desrochers S, Munday J, Clark J, Sherwin R, Gebrezghi M


Preparing for participation in the centers for Medicare and Medicaid Services’ bundle care payment initiative—advanced for major bowel surgery
Collins CR, Abel MK, Shui A, Intinarelli G, Sosa JA, Wick EC

Utilization patterns and efficiency gains from use of a fully EHR-integrated COVID-19 self-triage and self-scheduling tool: a retrospective analysis  
Judson TJ, Pierce L, Tutman A, Mourad M, Neinstein AB, Shuler G, Gonzales R, Odisho AY

Messaging About COVID-19 Safety Measures is Counterproductive in Cancer Screening Outreach: Results of a Pragmatic Randomized Trial 
Grumbach K, Gagliardi K, Coleman Hernandez S, Intinarelli G

Patient Experience and Feedback After Using an Electronic Health Record-Integrated COVID-19 Symptom Checker: Survey Study
Liu AW, Odisho AY, Brown Iii W, Gonzales R, Neinstein AB, Judson TJ

Automated telephone follow-up programs after hospital discharge: Do older adults engage with these programs?
Harrison JD, Sudore RL, Auerbach AD, Shah S, Oreper S, Wheeler MM, Fang MC

Cultivating Partnerships for Practice and Policy Relevant Health Research: Lessons Learned from the UCSF Population Health Data Initiative (poster)
Kemper KE, Fields JD, Rubinsky AD, Meltzer D, Domingo KB, Grumbach K, Collins P, Intinarelli G, Taylor B, Packer T, Lyles CR

The Transitional Care Model: A Randomized Controlled Trial (poster)
Brinker E, Jones D, Lee N, Li A, Snyder A, Wheeler M, Zarkower A

Reducing Disparities in Blood Pressure Control in Black/African American Primary Care Patients With Hypertension (poster)
Appelle N, Cheng K, McGuirk C, McNey E, Soares N, Yang N, Calderon A, Connors C, Cruz R, Gagliardi K, Morrell M, Pascual M, Tolliver T,  Hsia S, Stebbins M, Wong S

STEDDI (Short-Term ED Discharge Intervention) (poster)
Andersen R, Clark J, Desrochers S, French M, Gebrezghi M, Salcido L, Sherwin R, Fahimi J, Judson TJ

MAACC (Medicare Advantage & ACO Complex Care) OPH Care Support Program (poster)
Andersen R, Clark J, Desrochers S, French M, Gebrezghi M, Leon R, Salcido L, Sherwin R, Walsh J


Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues
Malevanchik L, Wheeler M, Gagliardi K, Karliner L, Shah SJ

Extending the Population Health Workforce Through Service Learning Internships During COVID: A Community Case Study
Belkora J, Weinberg T, Murphy J, Karthikeyan S, Tran H, Toliver T, Lopez F, Tominaga G, Helle M, Intinarelli G, Adler J

COVID-19 Symptom Checker MyChart Self-Triage & Self-Scheduling Tool (poster)
Judson T, Miller C, Williams A, Gonzales R

Designing a Transitions Social Worker Role in Population Health to Support Patients Post-Discharge (poster)
Snyder A, Lee N, Hoyt A, Casey J, Maxon E, Asiano M, Wheeler M

Building a System for Inpatient Addiction Management at UCSF Health (poster)
Sankaran S, Tierney M, Twiford J, Bazinkski M, Ristau J, Singh M

Short-Term Emergency Department Discharge Intervention (poster)
Clark J, Desrochers S, French M, Salcido L, Sapiro L, Sherwin R, Judson T, Andersen R

Increasing Annual Wellness Visits in UCSF Primary Care (poster)
Tutman A, Tang T, Askin E

COVID Vaccine Clinic - Informatics (poster)
Sweis S, Murray S, Coleman S, Tutman A


An Automated Telephone Call System Improves the Reach and Cost-effectiveness of Panel Management Outreach for Cancer Screening
Gagliardi KS, Coleman S, Intinarelli G, Karliner L, Appelle N, Taylor B, Grumbach K

Rapid design and implementation of an integrated patient self-triage and self-scheduling tool for COVID-19
Judson TJ, Odisho AY, Neinstein AB, Chao J, Williams A, Miller C, Moriarty T, Gleason N, Intinarelli G, Gonzales R

Nurse practitioner students as an essential workforce: The lessons of coronavirus disease 2019
Intinarelli G, Wagner LM, Burgel B, Andersen R, Gilliss CL


Social Determinants of Health: Mitigating Social Isolation & Loneliness (poster)
Garcia D, Trinh E, Andersen R, Clark J, Lee N, Sapiro L, Sherwin R

Safety of High Risk Medications on Discharge for Patients with Hip Fracture (poster)
Clark M, French M, Thibault A

Managing Population Health - Pediatric Asthma (poster)
Burkart B, Andersen R, Intinarelli G, Atkinson-McEvoy L, Park N


Care Support: Improving Interdisciplinary Case Conferences to Monitor Utilization Due to Ambulatory Care Sensitive Conditions (ACSCs) (poster)
Alipio R, Andersen R, Ritchie C, Thibault A, French M, Sapiro L, Clark J, Bianconi J, Burkart B, Jones D, Noland R, Toliver T

Innovations in Accessing Appropriate Levels of Care (poster)
Thibault A, Sapiro L, French M, Clark J, Noland R, Bianconi J, Clark M, Robbins S, Andersen R, Ritchie C


Many Neurology Readmissions Are Nonpreventable
Le ST, Josephson SA, Puttgen HA, Gibson L, Guterman EL, Leicester HM, Graf CL, Probasco JC

The Cohort Management Program: Optimizing Chronic Illness and Depression Management Through Team-based Care (poster)
Birch K, Andersen R, Alipio R, Jones D, Toliver T

Patient Driven Outcomes (poster)
Thibault A, Sapiro L, French M, Clark J, Andersen R, Ritchie C, Thompson N


Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life
Ritchie C, Andersen R, Eng J, Garrigues SK, Intinarelli G, Kao H, Kawahara S, Patel K, Sapiro L, Thibault A, Tunick E, Barnes DE

Weighting Primary Care Patient Panel Size: A Novel Electronic Health Record-Derived Measure Using Machine Learning
Rajkomar A, Yim JW, Grumbach K, Parekh A