Disparities Next Door: PCCI’s Community Vulnerability Compass spotlights areas of increased vulnerability across Dallas County
Dallas, Texas(Sept. 19, 2024) – Researchers at Parkland Center for Clinical Innovation (PCCI) have highlighted areas of increased vulnerability within Dallas County after conducting an analysis using PCCI’s Community Vulnerability Compass (CVC). The findings include a number of pockets of highly vulnerable areas within many low vulnerability ZIP Codes.
PCCI’s CVC analyzes, at the ZIP Code, census tract, and block-group level, where a community’s most vulnerable residents live and the root cause factors limiting these residents’ ability to thrive. The CVC analyzes 26 clinical and socio-economic indicators that reveal the health, resiliency, and economic vibrancy of neighborhoods. CVC’s analyses provide true, holistic pictures of who needs the most assistance and where to find them, enabling proactive support of those in need.
It is well-documented that many ZIP Codes in the south and southeast areas of Dallas County (see image 1) are home to long-standing socio-economically disadvantaged populations and have the highest vulnerability rating. However, PCCI’s analysis underscores what Parkland and other officials have long stated: that in addition to the south and southeast regions, there are other ZIP Codes in Dallas County with low vulnerability but are home to highly vulnerable block groups. Specifically, these include 18 Dallas County ZIP Codes with an overall very low or low vulnerability rating that contain within them 48 block groups with high or very high vulnerability ratings. The 18 ZIP Codes have a total population of 590,971, with 72,954 (12.3%) of their residents living in these very high vulnerability blocks groups.
“In some cases, we find that a very high area of vulnerability is across the street from a very low area of vulnerability.“
Steve Miff, phd, President and CEO of PCCI
The “very high” designation indicates that these neighborhoods are in the top 20% of vulnerability when compared to the rest of Dallas County. CVC vulnerability groupings are localized to the Dallas County geography and broken into quintiles and clustered into very low, low, moderate, high and very high areas.
“For good reason we focus a lot of our efforts on supporting the underserved communities in south and southeast Dallas County, but CVC empowers us with refined geographic precision to examine our broader community and uncover data that provides a high-resolution understanding of social vulnerability factors within other micro-geographies in our community,” said Steve Miff, PhD, President and CEO of PCCI. “In this examination, CVC highlights areas of deprivation that may be masked by gentrification and/or historical surrounding prosperity. In some cases, we find that a very high area of vulnerability is across the street from a very low area of vulnerability.”
For example, ZIP Code 75206, located in the Greenland Hills area that runs along Highway 75 and is bordered by Highway 12 and Skillman Avenue, is rated very low vulnerability by the CVC, but includes four block groups that are rated by the CVC as high and very high vulnerability. In this ZIP Code, which has a total population of 38,209, there are 2,661 (7%) who experience high or the very highest levels of vulnerability as measured by the CVC.
One ZIP Code of note, 75254, located north of the Galleria between Dallas North Tollway and Coit Road, has an overall low vulnerability rating, but includes 8 high or very high vulnerability blocks. Of this area’s total population of 24,047, 12,522 (52.1%) residents experience high or very high vulnerability. (see Image 2)
Additionally, ZIP Code 75230, which is considered to be an economically advantaged area in North Dallas between Walnut Hill and Interstate 635, includes a very high vulnerability block group.
“The lesson is that we need to look beyond our expectations and understand that disparities and vulnerability are all around us no matter how prosperous a given area may appear,” Miff said. “We hope this will bring an additional level of high-resolution, hyper-localized understanding of social vulnerability factors and empower leaders across all communities with relevant information to improve and sustain the lives of all Dallas County residents. North Texas has outstanding public health leaders who are doing a great job supporting vulnerable populations throughout the county and we hope this helps them as well as policymakers, community-based organizations and others who are vested in helping mitigate disparity.”
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About PCCI
The Parkland Center for Clinical Innovation (PCCI) is a not-for-profit, mission-driven organization with industry-leading expertise in the responsible application of artificial intelligence, machine learning and SDOH data modeling to address the needs of vulnerable populations. PCCI started as a department within Parkland Health and was spun out as an independent organization in 2012. PCCI strives to leapfrog the status quo by harnessing the transformative potential of data. Our unique capabilities allow us to provide innovative, actionable solutions that more effectively identify needs, prioritize services, empower providers, and engage patients.
AI Is Working For Us Now, Helping Us Heal and Prevent Harm
By Steve Miff, PhD, President & CEO of PCCI
We can’t let artificial intelligence (AI) continue to be defined by science fiction, deep fakes, and plagiarized term papers, because today―right now― responsible uses of AI in medical care are helping prevent harm, improve clinical decisions, and reduce costs of care. Is there too much unjustified hype and exuberance over AI? Absolutely! Are there unsubstantiated claims and sometimes dangerous promises? Unfortunately, yes. However, there are also many examples of ethical, responsible and equitable uses of AI that are streamlining operations, improving efficiencies, and yes, even helping physicians and clinical teams augment their insights and expertise to save lives.
AI is also not new. While the history of artificial intelligence (AI) can be traced to antiquity hypothesized by master craftsmen, modern AI really started with the invention of the programmable digital computer based on mathematical reasoning in the 1940s. In the last decade, the true potential (and risk) of AI and Machine Learning algorithms have accelerated and can simply be classified into predictive, prescriptive and generative AI/ML, with the latter creating the most excitement and controversy over the last 12-24 months.
At PCCI, we have been researching, developing, deploying and testing applications of AI and machine learning for a decade with a focus on applying these innovative concepts to those who serve the most vulnerable individuals and communities. With every project that we’ve embarked on, we’ve followed sound scientific principles and a prescriptive approach to development, testing and implementation that keeps the clinician in full control and with the utmost transparency, and the patient at the center. While the AI part is sexy, the governance, processes, and discipline you put around it makes it reliable, responsible and effective. We developed and optimized our own processes over type and rely on a core set of core principles:
There needs to be a clearly articulated problem and need that the AI is trying to solve/augment. If you don’t have a real problem to solve, it’s just cool math.
A multi-disciplinary team that includes an engaged and passionate lead clinician is required from day 1. The front-line staff already have the knowledge and intuition of what is needed and what could work.
More than half the time is spent on ensuring data quality and staging – researching, curating, studying, aggregating, ingesting, validating, augmenting and analyzing data from multiple sources is the lifeblood of any successful model. The old saying of “junk in, junk out” is even more crucial with AI.
Focus just the data required for the initial development, but understanding the required data latency, refresh frequency, storage and compute requirements to understand deployment requirement and cost to operationalize and sustain.
You need your own AI sandbox and your EHR is not it. PCCI developed Isthmus™, a secure, digital data environment leveraging established cloud technology and optimizing open-source tolls for end-to-end, secure data orchestration, modeling and deployment.
Data security is paramount, hence why PCCI deploys Isthmus™ within the firewalls of a health system/payer/provider (no protective data is moving out)
There is a prescriptive stage-gate development and deployment process that requires patience and time:
Build models leveraging historical data; T
Test the preferred model with a reserved data set
Optimize the performance of the model leveraging clinician input to optimize how the model is to perform and be used in practice
Deploy the model with real-time data and run it silent mode. No decisions are made using the model, but the performance, stability, expected output is evaluated and monitored. Evaluate for equity and expected performance on the respective patient population. This could take months, or years. If you’re trying to predict a rare event, it will require extensive time to ensure adequate amount of time and data is being processed. To ensure proper evaluation for the PCCI Parkland Trauma Mortality (PTIM), we went into a full silent mode on every patient every hour for 3 full months before we moved to provider facing production.
Design the output and display of the model and integrate into the EHR or case management system where clinical teams do their work (no extra clicks or sign-on to get to the information). Integrate and deploy systems that give clinical teams insights into the metrics behind the model. PCCI developed and deployed a web-based interface called Islet™ that provides real-time insights into a model. This is critical not only to ensure transparency to clinical teams, but it’s extremely valuable to point to the top factors and the data driving the algorithms to point to the factors that can be actioned
Design a stages go-live deployment process and incrementally expend teams and/or department while evaluating each deployment
Ensure a robust and coordinate response process to address off-cycle failures. While the models are designed to augment clinical decisions, the power of AI is tangible and useful and clinical teams rely on their assistance. It’s like getting used to driving on automatic transmission car and then having to go back to driving stick. You can still drive, but it’s not as easy.
This is not a one-and-done. Far from it. Develop and stick to a regular cycle of model evaluation, testing and updates
At PCCI speed to market is a self-imposed urgency and profits are not a measure of success. What our AI and machine learning systems aim to do is help providers make more informed clinical decisions, optimize resources to expand access, offer synthesized data insights that help improve health outcomes, and educate our region’s health leaders and residents.
Some of these AI predictive model applications came to life during the COVID-19 pandemic. We were able to use the established infrastructure, processes and expertise to create several programs that made significant impact on how Dallas County managed through the pandemic. A few of these AI and predictive models included:
Capacity Forecasting Model. Leveraging an AI algorithm based on geo mapping, we helped Parkland manage resources by creating an effective model that helped forecast possible needs for hospital beds, ICU, staffing needs, and development of workflows.
Proximity Index (PI). This AI predictive triage model empowered frontline clinical and population health teams to proactively manage high-risk patients and reduce potential COVID spread from asymptomatic patients in hospital and community settings.
Vulnerability Index (VI). This AI predictive model allowed public health leaders to understand the hardest hit populations in Dallas County and then drive community response.
Beyond COVID, PCCI’s AI-driven clinical decision support and population health programs guide policy and direct resources where they are needed most. PCCI’s team members have extensive experience deploying, testing, and validating a wide array of multi-institution, algorithm-driven protocols in clinical settings. Examples include:
Parkland Trauma Index of Mortality (PTIM)
The PTIM machine learning algorithm is the only known model that uses electronic medical record data to predict ―every hour ― 48-hour mortality during the first 72 hours of hospitalization, thus evolving with the patient’s physiologic response to trauma. Over a one-year period, PTIM has correctly identified 89% of the high-risk trauma patients and 92% of the low-risk trauma patients.
Inpatient (IP) Medicine Sepsis AI Program
The sepsis management system is real-time predictive model that identifies and triggers interventions of patients who are at high risk for sepsis both upon presentation and after being admitted to the hospital. The IP Sepsis model is unique as it enables Parkland to identify cases of sepsis that were not present on admission.
STI-HIV PrEP Model
The model will be able to predict those at-risk for hiv infection and eligible for prep in order to reduce HIV transmission. The PrEP predictive model is being developed using data from Parkland’s EHR, pertinent public open-source data on SDOH, and DCHHS STI data. The model will be able to predict those at-risk for HIV infection and eligible for PrEP to reduce HIV transmission.
Preterm Birth Prevention (PTB) AI-driven Program
To better serve pregnant women, PCCI and the Parkland Community Health Plan developed and implemented an innovative Preterm Birth (PTB) Prevention program that uses a machine learning algorithm, healthcare data, and social determinants of health to identify pregnant women who are at a higher risk of PTB within vulnerable communities. The PTB program consistently risk stratifies about 13,000 pregnant women from vulnerable communities per year.
Pediatric Asthma Surveillance System (PASS)
PCCI developed the PASS to help prevent pediatric asthma from harming children in Dallas by providing a single source of community insights to identify children that have higher vulnerability to poor asthma outcomes and highlight areas of health disparities. The PASS interactive dashboard has been visited by nearly 3,000 Dallas County residents.
Many of these programs have proven to be cost effective, scalable and successful. We will continue to invest and explore new ways to apply AI solutions in collaboration with some of the top healthcare providers and public health organizations in the nation.
Whether everyone knows it, understands it or even likes it, AI is here to stay and is exploding in healthcare, and making a huge difference in our lives. At PCCI we will continue to focus on applying and localizing these powerful concepts with those who serve the most vulnerable individuals and communities. That’s our mission and focus and will remain that way. This specifically means continuing our work with Parkland Health (Parkland), PCHP, Dallas County Health & Human Services Department (DCHHS), the United Way of Metropolitan Dallas, and expanding our partnerships with other similar organizations in San Antonio, Austin, Atlanta and other communities.
Because of the responsibility that has been entrusted in us, we feel the urgency and responsibility to not only continue to learn from others pioneering responsible applications of AI, but contribute to the knowledge, voice and narrative of AI nationally. That’s why we’re appreciative to be included and actively participate in national AI committees and collaboratives, such as the Health AI Partnership advisory board, the National Academy of Medicine AI Adoption and Code of Conduct committee, the White House Health AI commitments executive group, as well as several other national meetings and forums. We bring the important perspective and the unique challenges of leveraging these new and exciting capabilities in an equitable was and make these innovations accessible to underrepresented and underserved communities.
For many the promise of AI is about what’s on the horizon, but I see the promise of AI delivering results and innovations today. With responsible, equitable, reliable and transparent applications, the future is now.
About Steve Miff
Dr. Steve Miff is the President and CEO of Parkland Center for Clinical Innovation (PCCI), a leading, non-profit, artificial intelligence and cognitive computing organization affiliated with Parkland Health, one of the country’s largest and most progressive safety-net hospitals. Spurred by his passion to use next-generation analytics and technology to help serve the most vulnerable and underserved residents, Steve and his team focus on leveraging technology, data science, and clinical expertise to obtain unique social-determinants-of-health data and incorporate those holistic, personal insights into point-of-care interventions. Steve was the recipient of the 2020 Dallas Business Journal Most Inspiring
University Health Transplant Institute partners with Parkland Center for Clinical Innovation to implement innovative data management to improve patient outcomes
Dallas, Texas – University Health Transplant Institute, dedicated to restoring health and life to patients with organ failure through prevention treatments and transplantation services, is partnering with the Parkland Center for Clinical Innovation (PCCI). The goal of this partnership is to improve care and outcomes by combining artificial intelligence with clinical expertise, to enhance the Transplant Institute’s digital data environment allowing for enhanced data access and advanced analytics to enable transformative innovation and high-impact research.
Currently in the implementation phase, PCCI is expanding University Health’s capabilities based on deploying PCCI’s innovative, cloud-based, digital data environment, ISTHMUSTM, and leveraging PCCI’s Community Vulnerability Compass (CVC), a non-medical drivers of health (NMDoH) data integration and visualization tool enabling deeper understanding of the context and complexities of the social barriers to health, access and well-being of Transplant Institute patients. The CVC uses 26 clinical and socio-economic indicators clustered into four thematic domains denoting the health, resiliency and economic vibrancy of neighborhoods. The first application of these innovative digital technologies and enriched data assets was the launch of the industry-leading Transplant Quality and Research DataMart, an important collaboration between University Health Transplant Institute and PCCI.
“With the rollout of PCCI’s Transplant Quality and Research DataMart, these projects will take just hours to complete. This reduced time to make data available to our fabulous team, in turn, will speed up our research and quality processes by enabling our physicians and staff to access data exponentially faster as they work to save more lives.” – Francisco G. Cigarroa, MD, Professor of Surgery and Director, Alvarez Transplant Center
In partnership with UT Health San Antonio, the University Health Transplant Institute is one of the top five U.S. transplant centers based on survival outcomes in kidney, liver, and lung transplantation. Its innovations in clinical practice and management have driven utilization of higher-risk donor organs and expanded opportunities for more patients to receive lifesaving transplantation. The Transplant Quality and Research DataMart will be able to place equitable data insights in the hands of research and care teams, while serving as a catalyst to new breakthroughs in understanding barriers and their impact to health, and ultimately providing higher quality of care to residents of Bexar County and beyond.
“We are proud to support University Health and its mission to provide high impact and innovative care,” said PCCI CEO, Steve Miff, PhD. “Our work will support University Health’s position as a leader in the transplant field with the implementation of a digital data environment and a transplant quality and research DataMart. This will allow the University Health Transplant Institute team to enhance and extend research and outcome studies and expand cross-industry collaborations. Adding CVC, our advanced NMDoH analytics tool, University Health will be better able to understand the NMDoH for their whole transplant population and better serve and provide enhanced access and support for their patients across the state.”
“Our Transplant DataMart is the first of its kind to use data from a large transplant program in a standardized cloud-based format by incorporating clinical metrics and non-medical drivers of health that are connected to a network of databases and other researchers across the world. This unique system will help us improve outcomes for transplant patients, perform advanced analytics, reduce barriers to care and increase grant and research opportunities to expand and share our work,” said Bryan Alsip, MD, Executive Vice President and Chief Medical Officer of University Health.
This partnership will help University Health foster additional grant and research opportunities by moving the organization into the Observational Health Data Sciences and Informatics (OHDSI) program. OHDSI is an international network of researchers and observational health databases with a central coordinating center housed at Columbia University. Integrating OHDSI, the OMOP Common Data Model, and the OHDSI software tools into the UH ISTHMUS™ ecosystem enables University Health teams’ access to the open community data standards, open-source software, and ways to apply scientific best practices to generate reliable clinical evidence.
Also, PCCI’s CVC will allow the University Health Transplant Institute to analyze a patient’s NMDoH to help make informed, equitable decisions. The CVC gives the team the ability to query a patient’s address to assess the NMDoH factors impacting that patient’s residential block group. This informs and enables more targeted screening questions and the collection of enhanced data to facilitate collaboration with community and health care organizations to support current and prospective patients throughout their transplant journey.
“University Health Transplant Institute has a 53-year history of cutting-edge innovation and superior survival rates. We are now one of the two largest living donor programs in the US and number one in survival. We also have the top survival and transplant rates for kidney and lung in our region including pediatrics. We have continually expanded access to our unique patient population through new medical techniques in lung, liver, and kidney transplantation and hepatocellular tumors and cancers,” said Francisco G. Cigarroa, MD, Professor of Surgery and Director, Alvarez Transplant Center, Malú & Carlos Alvarez Distinguished University Chair, and Ashbel Smith Professorship in Surgery.
“However, data projects to analyze and share our successes, can take us weeks or even months to complete. With the rollout of PCCI’s Transplant Quality and Research DataMart, these projects will take just hours to complete. This reduced time to make data available to our fabulous team, in turn, will speed up our research and quality processes by enabling our physicians and staff to access data exponentially faster as they work to save more lives. This in turn will lead to better outcomes and enhanced access to life-saving transplantation. This also allows us to share our successes with the transplant community around the world to make lives better,” Cigarroa added.
ABOUT UNIVERSITY HEALTH
University Health is the only locally-owned health system in San Antonio. For more than 100 years, University Health has been here to heal, improve health, train the next generation of medical professionals and ensure the people of San Antonio, Bexar County and South Texas have access to primary and advanced specialty care close to home. Specialized services include the region’s only Level I trauma center for both adults and children, and maternal and neonatal intensive care centers designated at the highest levels by the State of Texas. As the region’s only academic health system, University Health is a hub of innovation and discovery, committed to delivering patient-centered, culturally competent, high-quality and compassionate care, based on a strong foundation of outcomes‐based research and innovative teaching. Learn more at UniversityHealth.com.
About PCCI
The Parkland Center for Clinical Innovation (PCCI) is a not-for-profit, mission-driven organization with industry-leading expertise in the practical applications of artificial intelligence, machine learning and SDOH data modeling to address the needs of vulnerable populations. PCCI started as a department within
Parkland Health and was spun out as an independent organization in 2012. PCCI strives to leapfrog the status quo by harnessing the transformative potential of data. Our unique capabilities allow us to provide innovative, actionable solutions that more effectively identify needs, prioritize services, empower providers, and engage patients.
North Texas Giving Day: Join us in our journey to bring health innovation to the most vulnerable communities
North Texas Giving Day, set for Sept. 19 but open to donations now, is a powerful opportunity to unite our community in supporting the causes we care about most. At PCCI, our team of clinicians and expert data scientists strive to support the health of vulnerable communities in North Texas through the responsible applications of AI and non-medical drivers of health (NMDoH) analytics. NMDoH are the conditions in the places where people live, learn, work and play (e.g., food insecurity, housing, transportation) that affect a wide range of health risks and outcomes. These external social, economic and environmental factors have been shown to be responsible for upwards of 80% of what keeps us healthy or, conversely, leads to illness and an impaired quality of life. As a non-profit, your support is critical to this mission.
Why support PCCI? You may have felt the impact of PCCI’s innovative AI and NMDoH programs during the COVID-19 pandemic when you learned about the spread of the infection through our neighborhoods. Or if you’ve checked the Dallas County Health & Human Services Department’s Pediatric Asthma Surveillance System dashboard―developed by PCCI― that offers insights into the asthma risks on your neighborhood. And you may know a pregnant woman who was able to bring their child to full term thanks to the Parkland Health’s Preterm Birth Prevention program powered by PCCI’s AI. We aim to ensure that each of our innovations are targeted to the unique needs of our community and equitably applied and support the most vulnerable in our neighborhoods.
Your Support is Critical in Creating Opportunities for Women in Technology
Benefiting the most from your support will be PCCI’s women in data science intern program, the Sachs Summer Scholars. PCCI developed this STEM-focused program to help open doors to women seeking careers in data science.This is an industry challenge as, according to Girls Who Code, from 1984 to today, the number of female computer science graduates dropped from 37% to 18% and computing degrees are less likely to be awarded to women in all racial and ethnic groups. These trends are taking place in spite of the fact that women outnumber men overall at universities. At PCCI we are committed to reversing this trend and improving diversity in the data science and technology industry all while focusing their contributions, efforts and learnings towards innovative, practical solutions supporting our local community.
Your support will enable PCCI to continue to provide unrivaled opportunities for undergraduate, graduate and doctoral female students from diverse backgrounds to work side-by-side with PCCI data scientists and clinicians and directly contribute to projects benefiting the community such as improving maternal health and pediatric asthma outcomes, lowering suicide risk, and developing a community surveillance system for diabetes and hypertension. In 2024, PCCI reported that 71.43% of participating interns were from diverse ethnicities. PCCI’s internship program helps these students to improve their self-confidence, hone their programming and analytics skills in order to open up greater career opportunities, fuel their passion for learning and helping their community, and build lifelong memories of meaningful accomplishments.
Our programs have proven to be cost effective, scalable, and successful. With your support, we will continue to explore new ways to apply AI solutions in collaboration with some of the top healthcare providers and public health organizations in the nation.
Early giving is open now, and every dollar counts. Your donation today will help us build momentum and maximize our impact on North Texas Giving Day. Together, we can create a brighter future for our community. Support PCCI in shaping the future of healthcare technology in North Texas.
Click here to donate now and be a part of the change!
PCCI introduces its 2024 class of Sachs Summer Scholars Interns
STEM focused program sets female students side-by-side with AI experts, data scientists and clinicians
PCCI’s summer intern program, Sachs Summer Scholars, Advancing Women in STEM and Technology Summer Internship, has begun, demonstrating PCCI’s ongoing commitment to improving gender diversity in the data science and technology industry. This program has become the one of the premier internship in North Texas that immerses students in meaningful, real word projects with actual impact. This includes providing each intern direct experience with innovative healthcare, groundbreaking artificial intelligence programs and social determinants of health projects. The aim is to support and promote practical applications of analytics, computing, and data science all while advancing the spirit of mentorship and advancement of female students.
The 2024 class of Sachs Summer Scholars includes seven women from diverse backgrounds, hailing from six different universities. Working side-by-side with PCCI clinical and data science experts to hone their programming and analytics skills while building life-long memories of meaningful accomplishments, the interns will work on core projects at PCCI including: disease surveillance systems, brain care predictive modeling, suicide risk screening, jail health and pediatric asthma risk prediction, to name a few.
This class will present findings based on their work with PCCI at a presentation on August 9th, at Pegasus Park.
The interns are, from left to right: Ozgur Aksoy, University of Texas – Dallas; Serap Ogut, Southern Methodist University; Autumn Carey Noon, Ohio State University; Bengisu Yarimbas, University of North Texas; Emily Thompson, Southern Methodist University; Ferona Bustani, University of Texas – Austin; Saniah Safat, University of Texas – Austin.
Cracking the Nutritional Puzzle: A Path Out Of Dallas’ Food Desert
By Olayide “Olay” Adejumobi, Project Manager, PCCI
Recently, I was shocked to hear that North Texas is one of the hardest hit areas of the country for food insecurity. Shocked, but not surprised. As a registered dietitian and a participant in PCCI’s management of the Dallas Accountable Health Community (DAHC)[1] program, I have seen the Dallas County’s food depravations firsthand, and while this food desert may seem trackless, I believe that by using data, we have ways to create oases.
It turns out that Dallas County has the highest rate of food insecurity among counties in North Texas, with a rate of 15.6%, which is approximately nearly 407,000 residents, per a new report from Feeding America released by the North Texas Food Bank.
I couldn’t agree more with the statement made by Trisha Cunningham, President and CEO of the North Texas Food Bank, “In North Texas, where hunger affects more people than the populations of cities like Seattle or San Francisco, the most alarming statistic is that nearly 40% of those in need are children—a situation that is simply unacceptable.”
As an expert in nutrition, public health, I can tell you that the effects of food insecurity are pernicious and corrosive to families, communities and entire populations. These effects include:
Overall poor health and increased likelihood of chronic illnesses such as diabetes, cancer, heart disease, and stroke
Mental and social stresses of food insecurity, can lead to social isolation and stigma, while leading to depression due to heightened stress and anxiety
Declining academic success: Children who have food insecurities may see an adverse effect on their mental and physical health, reducing their educational opportunities
Ending in 2022, PCCI managed the DAHC[1], a five-year initiative that tested whether identifying and addressing health related social needs of Medicare and Medicaid beneficiaries such as housing instability and quality, food insecurity, utility needs, interpersonal safety, and transportation, would reduce both in health costs and emergency department utilization – we found it did. As a part of the team, I was witness to the myriad of social, economic and health issues the most underserved residents of Dallas faced.
What I can tell you is that food insecurity isn’t just a statistic― it’s a lived reality for many in the southeastern areas of Dallas County.
What I can tell you is that food insecurity isn’t just a statistic― it’s a lived reality for many in the southeastern areas of Dallas County. I’ve seen how non-medical drivers of health can amplify health disparities and lead to adverse health outcomes when quality, nutritious, and affordable food isn’t within reach. The people in these areas grapple with food insecurity due to a complex interplay of non-medical factors. Which makes solving this issue more that just having grocery stores available in those areas, though that would definitely be a good start. The challenges these areas face include:
Economic Challenges: The neighborhoods in southeast Dallas have high poverty rates, making it a daily struggle for residents to afford nourishing food. Families often find themselves compelled to prioritize cheaper, less nutritious options due to limited financial resources.
Transportation Barriers: Full-service grocery stores, where fresh produce and essential items are readily available, are scarce in these areas, and the lack of reliable transportation compounds the problem, preventing residents from reaching distant grocery stores and compelling them to settle for less healthy options closer to home.
Educational Disparities: Low educational attainment in these areas leads to limited knowledge about nutrition and healthy eating, making it a daunting task for residents to make informed food choices.
My journey inside the community data PCCI collected has been an eye-opener. But it’s not just about the numbers we see; it’s about understanding the lives and stories behind those data points. Armed with this information, we have the potential to embark on a path to address food insecurity in these communities through:
Community Health Workers: These unsung heroes bridge the gap by providing education, resources, and emotional support to individuals and families in need. They connect people to local resources like food banks and assistance programs and help them develop coping strategies.
Community-Led Initiatives: Data-driven strategies can empower grassroots organizations and community leaders to tackle food insecurity head-on. With the PCCI’s data, we can pinpoint, at the block-level, areas of the greatest need and tailor interventions accordingly.
Local Government Support: Guided by data-driven insights, local government officials can allocate resources more effectively. Advocacy for policies promoting the establishment of grocery stores and farmers’ markets can be rooted in this specific data.
Transportation Solutions: PCCI’s data also identifies transportation deserts within the most underserved areas of Dallas, paving the way for improved public transportation options. This strategic approach can ensure residents can access grocery stores with greater ease.
Education and Outreach: Customized nutrition education programs and workshops, based on PCCI’s data, can empower residents to overcome educational disparities and make healthier food choices.
Since the conclusion of the DAHC program, PCCI has developed the Community Vulnerability Compass (CVC), which provides actionable data regarding social barriers to health, access, and well-being of a community’s most vulnerable populations at the block group level. This includes insights into the number of individuals who are eligible for Supplemental Nutrition Assistance Program (SNAP) benefits, which is a leading indicator of food insecurity.
With the CVC, PCCI has been able to learn more about the pressing issues at the block group level in the hardest hit areas of southeast Dallas. PCCI’s data has reinforced the importance of understanding the unique challenges faced by these communities. Through leveraging this data, we can develop new community-led initiatives to engage residents and foster healthier, more resilient communities. The ultimate goal is to ensure equitable access to resources that enable all Dallas residents―regardless of their neighborhood, to lead healthy and fulfilling lives.
About Olayide “Olay” Adejumobi
Olay is a seasoned healthcare professional with ten years of clinical experience and five years of medical nutrition therapy and disease management experience. As a clinical project manager, she collaborated with cross-functional key stakeholders primarily focused on patient outcomes. She earned a Bachelor of Science in Nutritional Science and Public Health plus a Master’s degree in Healthcare Administration and Information Analytics from Texas Tech University.
[1] This project was supported by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $4.5M with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CMS/HHS or the U.S. Government. Although PCCI’s participation in the AHC Model is now over and CMS is no longer affiliated, we are continuing aspects of the program established during our participation in the Model.
Pegasus Park Non-profit Innovators Collaborating with PCCI’s Community Vulnerability Compass, Offering Custom Data Insights to Accelerate Each Organization’s Efforts
Sponsored by the Water Cooler at Pegasus Park, The Dallas Foundation, and Lyda Hill Philanthropies, seven tenants at the Pegasus Park innovation hub are participating in a community of practice utilizing PCCI’s Community Vulnerability Compass (CVC) to help further their community-driven missions.
PCCI’s CVC is a technology toolkit that provides customized, foundational insights on community needs and complements insights generated by individual organizations. Through an easy‐to‐use web‐based dashboard, the CVC offers summarized information and root-cause details of neighborhood vulnerabilities that drive inequity. PCCI’s CVC is leveraged by organizations around the state, such as the United Way of Metropolitan Dallas, to improve their understanding of the community they serve. Through a fuller understanding of these root causes, these innovative organizations can better align efforts to create connected communities and develop better programs, resources, and interventions to eliminate disparities, achieve health equity, and improve the lives, health and well‐being of underserved residents and communities.
The participating Water Cooler-based organizations include innovative non-profits with missions to build a better community for all. They are:
The City Year AmeriCorps members serve in schools all day, every day, preparing students with the social, emotional, and academic skills and mindsets to succeed in school and in life.
The Grant Halliburton Foundation works to strengthen the network of mental health resources for children, teens, and young adults; promote better mental health; and prevent suicide.
The Junior Achievement of Dallas (JA Dallas), a nonprofit organization impacts the lives of students by teaching life skills in budgeting, careers, and business start-ups. JA Dallas’s mission is to inspire and prepare young people to succeed in a global economy through volunteer-delivered curriculum.
Social Venture Partners Dallas is committed to helping individuals realize greater impact with their giving, strengthening nonprofits, and investing in collaborative solutions.
Texas Trees serves as a catalyst in creating a new green legacy for North Texas through transformational, research-based plans that educate and mobilize the public to activate the social, economic, environmental, and health benefits that trees and urban forestry provide for a better quality of life.
The Commit Partnership is a collective impact organization composed of hundreds of partners across Dallas County and the state of Texas supported by a dedicated ‘backbone’ staff of 60+ professionals.
Established as the first community foundation in Texas in 1929, the Dallas Foundation brings together people, ideas, and investments in Greater Dallas so individuals and families can reach their full potential. Over the course of the Foundation’s history, it has granted over $1B to the full spectrum of community-centered causes.
“We are honored to partner with and support our colleagues at the Water Cooler at Pegasus Park with the capabilities that the CVC offers,” said Steve Miff, CEO of PCCI. “The program’s sponsors, Water Cooler at Pegasus Park, The Dallas Foundation, and Lyda Hill Philanthropies, are strong supporters of the missions of each of the participating organizations and we are exceedingly grateful to them for helping support these collaborations to build a better community.”
Water Cooler’s mission is to support organizations in their quest to attract and retain talent, engender collaboration among members, reduce administrative costs, and ultimately, increase collective impact on key social issues. Water Cooler’s nonprofit and philanthropic tenants are co-located among five floors and roughly 175,000 square feet within Pegasus Park’s main 18-story tower in Dallas. The Water Cooler at Pegasus Park is sponsored by Lyda Hill Philanthropies, in partnership with J. Small Investments and Montgomery Street Partners and managing partner The Dallas Foundation.
PCCI, founded in 2012, is a not-for-profit, healthcare innovation and research organization affiliated with Parkland Health. PCCI leverages clinical expertise, data science, and social determinants of health to address the needs of vulnerable populations.
In the News: Modern Healthcare – Using PCCI AI To Help Reduce Healthcare Violence
Modern Healthcare, the nation’s leading medical news source, is reporting on PCCI’s program that supports Parkland Health’s efforts to reduce workplace violence that protects all of its health workers.
PCCI’s CEO named a top AI leader by Dallas Innovates, and the Dallas Regional Chamber
Dallas Innovates, the Dallas Regional Chamber, and Dallas AI have teamed up to launch the inaugural AI 75 list. The 2024 program honors the most significant people in AI in DFW in seven categories—the visionaries, creators, and influencers you need to know. Included in this list, under the “AI Impact Innovators” category is Steve Miff, PhD, CEO of PCCI.
Listed as a “Healthcare Hero” the AI 75 sites many of PCCI’s successful implementations of AI modeling:
“Miff serves on multiple committees guiding AI policy and implementation at Dallas’s Parkland Center for Clinical Innovation, where he’s president and chief executive. Under his leadership, the nonprofit center has developed cutting-edge solutions using artificial intelligence to advance the health and well-being of underserved individuals and populations. Examples include a unique, in-patient model that can identify and intervene in high-risk sepsis cases; a system designed to prevent pediatric asthma; and an innovative, preterm birth prevention program to better serve pregnant women. Miff also has been active nationally, helping to draft codes of conduct and “best practices” guides as AI continues to progress at a rapid pace.”
WATCH: PCCI leader shares insight on emerging technology and behavioral health
In this video interview from HIMSS24 with Jacqueline Naeem, MD, PCCI’s Senior Medical Director, shares with FinThrive her views on what new technology innovations are supporting mental health as well as what passions drive her as a physician.
