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15 December 2020

Blog: Lean on Your Connected Community of Care in Times of Crisis




By Keith C. Kosel, PhD, MHSA, MBA
Parkland Center for Clinical Innovation

We’ve all experienced crises in our lives. They may be personal in nature (e.g., involving our interpersonal relationships), organizational (e.g., relating to our employment or retirement income) or nature-made (e.g., floods, tornados, or the COVID-19 pandemic). When crises hit our communities, the impacts can be widespread and far-reaching. Healthcare providers and community-based organizations (CBOs) are called upon to provide more rapid and extensive care and support to the community than is otherwise the norm. A well-established and highly functioning Connected Community of Care (CCC), as is the case here in Dallas, Texas, can provide a tremendous strategic and tactical advantage over non-connected peers.

Since 2014, the Parkland Center for Clinical Innovation (PCCI) has led an effort to bring together several large healthcare systems and a number of regional social-service organizations such as food banks, homeless assistance associations, and transportation service vendors, along with over 100 smaller CBOs (i.e., neighborhood food pantries, crisis centers, utility assistance centers) and area faith-based organizations to form the Dallas CCC. Over time, civic organizations, such as the Community Council of Greater Dallas, Dallas County Health and Human Services (DCHHS), and select academic institutions have begun to participate in various community-wide projects under the Dallas CCC umbrella. Central to the success of the Dallas CCC are the partnerships that have been formed between the CBOs and a number of local healthcare systems (Parkland Health & Hospital System [Parkland], Baylor Scott & White Health, Children’s Medical Center, Methodist Health System, and Metrocare Services), clinical practices, and other ancillary healthcare providers serving the Dallas metroplex. These partnerships have proved essential in building a truly comprehensive and functional network aimed at improving both the health and well-being of Dallas residents.

Connecting these various entities and forming a two-way communication pathway is an electronic information exchange platform termed Pieces™ Connect, which allows for real-time, two-way sharing of information pertaining to an individual’s social and healthcare needs, history, and preferences. The information exchange platform is the glue that holds the physical network together and provides one of the mechanisms to disseminate information from public health and healthcare entities to social service providers in the community. It allows the individual community resident, via the CBO, to become better informed about important health issues, such as routine vaccinations or preventive care, such as social distancing and proper mask usage during a pandemic.
Until recently, the primary mission of the Dallas CCC focused on addressing residents’ social determinants of health (SDOH) issues through providing community resources (e.g., food assistance, housing, transportation) to improve the lives of Dallas County residents. While this mission has become even more critical during the COVID-19 pandemic, the work of the Dallas CCC has also evolved to include identifying COVID-19 sites within the County and directing community outreach efforts to help stem the rapid spread of the virus.

The Dallas CCC has provided an innovative model of community governance and cooperation to impact the consequences of the COVID-19 outbreak. From the first days of the pandemic, PCCI has been working with Parkland and DCHHS to help reliably identify and quantify the geographic location and incidence rates of positive COVID-19 cases within Dallas County. This problem is especially challenging when considering vulnerable populations and the transitory nature of these residents in inner-city communities. Working with data provided by DCHHS, the Dallas-Fort Worth Hospital Council, and CBOs, PCCI built a series of dynamic geo-maps that were able to identify, at the neighborhood and block level, the location of hotspots of positive COVID-19 cases as well as attendant mortality rates. In addition to flagging at-risk patients and populations, the model continues to be used by public health and civic leaders to establish locations for testing sites within the city of Dallas based on COVID-19 incidence and community need.

With the establishment of the hot spotting, the next step was to get that information, along with general infection prevention protocols, in the hands of local CBOs to help raise awareness and slow the spread of the virus. With the aforementioned information in hand, public health workers have been able to develop targeted communications and tactical strategies to improve containment efforts through community-wide awareness and educational messaging. By connecting local CBOs and faith-based organizations with public health workers and clinicians, the Dallas CCC is facilitating effective contact tracing and the implementation of care plans for high-risk individuals in a more efficient and scalable manner.

The value of the CCC communication network linking healthcare providers and CBOs cannot be underestimated, as it represents a highly effective and efficient mechanism to disseminate leading practice information aimed directly at high-risk populations. We have seen first-hand that communications delivered to community residents through familiar food pantries, homeless shelters, and places of worship are much more effective than community-wide public information campaigns broadcast via radio or television. This increased effectiveness is based on the fact that many of these at-risk individuals frequent the CBOs on a regular basis for essential services and these individuals know and trust the CBO staff delivering the information. From one-on-one conversations to displaying infographic posters and take-away educational leaflets, CBOs provide a ready avenue to communicate with at-risk individuals in the communities they serve.

As mentioned, early work in Dallas County is beginning to demonstrate the value of CCC in facilitating contact tracing. In this case, the challenge is not simply identifying the location of positive COVID-19 cases but having the ability to connect those cases to other individuals within the neighborhood or community who may have come in contact with the infected individual, all while working in an environment where individuals frequently move from one location to another. Having a well-established communication system at the local neighborhood level can be extremely helpful in identifying contacts and potential contacts. It is well-known that many individuals in impoverished, underserved neighborhoods are reluctant to speak with individuals they don’t know or trust, especially if those individuals are affiliated with government agencies, no matter how well-intentioned the agency personnel may be. Staff members at local faith-based organizations and CBOs frequented by these vulnerable residents are a highly effective resource for identifying inter-personal relationships and connecting with those individuals, which is something that has proved challenging for public health staff when working outside of a CCC environment. In Dallas, CBOs, public health and civic staffers, as well as medical student volunteers have all been partnering to help facilitate the contact tracing process with positive results.

CCC’s can materially improve the health and well-being of a community’s residents, especially in times of crises. The take-away lesson is clear. If you already have a CCC, lean on it to help you through crises impacting your community. If you don’t have a CCC, now is the time to begin the process of establishing one in your community. Even with the challenges that the current pandemic is generating, it is possible to begin building your CCC. Start small and gradually increase the CCC’s scope and scale; don’t be in a rush to grow. The most important thing is to take the plunge and begin the journey!

About the author

Dr. Keith Kosel is a Vice President at Parkland Center for Clinical Innovation (PCCI) and is author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and underserved populations.

11 December 2020

In The News: D CEO Healthcare’s Thanksgiving Cautionary Tale Using PCCI Data




D CEO Healthcare, Dallas’ leading business and healthcare media network, has run a story featuring PCCI’s Vulnerability Index for COVID-19 in Dallas County. This story shares PCCI’s mobility findings during Thanksgiving that were similar to 2019, and gives caution to the upcoming Christmas holiday. To read the whole story, click on the image below:

7 December 2020

High Thanksgiving Mobility Adds To COVID-19 Threat, As PCCI’s Vulnerability Index Observes Dramatic Risk Increase in Dallas




DALLAS – As of November, Parkland Center of Clinical Innovations’ (PCCI) Vulnerability Index observed significant increases in vulnerability to COVID-19 infection in Dallas County as new cases rise affecting the Vulnerability Index (VI) value for some of the most at-risk areas of Dallas County. More troubling, is the 0.47% year-over-year in mobility during the Thanksgiving holiday, which is a similar rate compared to pre-pandemic Thanksgiving in 2019.

“PCCI analysis indicates a systemic increase in people leaving their home in the two-week period around Thanksgiving. Paired with the dramatic increase in the Vulnerability Index, our community will be challenged through the December holidays and into the first part on 2021,” said Thomas Roderick, PhD, Senior Director of Data and Applied Sciences at PCCI.

Launched in June, PCCI’s Vulnerability Index determines communities at risk by examining comorbidity rates, including chronic illnesses such as hypertension, cancer, diabetes and heart disease; areas with high density of populations over the age of 65; and increased social deprivation such as lack of access to food, medicine, employment and transportation. These factors are combined with dynamic mobility rates and confirmed COVID-19 cases where a vulnerability index value is scaled relative to July 2020’s COVID-19 peak value.

The Vulnerability Index reports that in November (See Table 1), the ZIP code with the highest vulnerability value continued to be 75211, around Cockrell Hill. This area has been a high-risk area since the launch of PCCI’s Vulnerability Index.

Table 1

The ZIP code 75204, which is northeast of downtown Dallas and intersected by U.S. Highway 75, now has the second highest VI value in Dallas County. The area has seen a rapid increase in its vulnerability since July when its VI value was outside the top ten most at-risk ZIP codes. Additionally, since October, this ZIP code had the biggest jump in its VI value in Dallas County, increasing 43.83 (See Table 2).

In general, the top five most vulnerable ZIP codes showed the most extreme increases and exceeded the highest values in as of November (See Table 2). The next five ZIP codes had growth but remain at a moderate VI levels. All ten ZIP codes had increased year-over-year mobility and reflect the COVID-19 case counts that have increased generally across the county.

“Overall, what we are seeing is the increase in confirmed COVID-19 cases and mobility drive an increase in vulnerability in Dallas County,” said Dr. Roderick. “Mobility and socioeconomic deprivation are highly correlated and a potential target for community and public health interventions. Socioeconomic factors affecting mobility include crowded living conditions, type and industry of work, especially client-facing jobs or crowded work environments.”

The PCCI COVID-19 Vulnerability Index can be found on its COVID-19 Hub for Dallas County at: https://covid-analytics-pccinnovation.hub.arcgis.com/.

Data Sources:
To build Vulnerability Index, PCCI relied on data from Parkland Health & Hospital System, Dallas County Health and Human Services Department, the Dallas-Fort Worth Hospital Council, U.S. Census, and SafeGraph.

 

Table 2

About Parkland Center for Clinical Innovation
Parkland Center for Clinical Innovation (PCCI) is an independent, not-for-profit, healthcare intelligence organization affiliated with Parkland Health & Hospital System. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations. We believe that data, done right, has the power to galvanize communities, inform leaders, and empower people.

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6 November 2020

In The News: DCEO Explores PCCI’s October COVID-19 Vulnerability Index




The new update to PCCI’s COVID-19 Vulnerability Index (and the animated heat map) is explored in a story by DCEO Healthcare. PCCI executives give expert insights into the data and information being tracking for COVID-19 in Dallas County. The story captured the outstanding work PCCI is doing to help the people of Dallas County fight the virus. Read it on the image below:

 

4 November 2020

HIMSS Webcast III: Connected Communities of Care and Bending the Cost Curve




https://www.himsslearn.org/connected-communities-care-and-bending-cost-curve

The healthcare cost curve continues to spiral out of control.  Programs such as accountable care and value-based purchasing are exemplar programs with bold cost-containment targets.  In addition, we know that non-health issues contribute to a significant portion of healthcare costs.  This session will specifically focus on where and how focusing on SDOH can impact costs.

Please have a look at the full set of HIMSS Webcasts featuring PCCI and Healthbox discussing how to implement SDOH principles via connected communities of care:

 

 

4 November 2020

HIMSS Webcast II: Connected Communities of Care and the Community Health Needs Assessment (CHNA)




https://www.himsslearn.org/connected-communities-care-and-community-health-needs-assessment-chna

Understanding community need has been a core aspect of hospital operations, especially for organizations with a non-profit status.  As we gain greater insights into the impact of non-medical determinants and their impact on positive health outcomes, there is a heightened imperative to revamp how CHNA activities are undertaken and the type of data that are collected.  This session will speak to how organizations who have been on the front lines of SDOH work have altered their approach to their CHNA to gain deeper insights to better contextualize the true needs of their communities. This webcast features PCCI and Healthbox leaders:

Please have a look at the full set of HIMSS Webcasts featuring PCCI and Healthbox discussing how to implement SDOH principles via connected communities of care:

 

 

4 November 2020

HIMSS Webcast I: Connected Communities of Care During Times of Crisis




https://www.himsslearn.org/connected-communities-care-during-times-crisis

In the first of three webcasts, we see that as the pandemic continues to unfold, it is painfully clear that underserved populations are at greater risk for COVID-19.  As such the importance of connections between clinical and community-based organizations is more important than ever.  This session will delve into how communities with operational connected communities of care have responded to the current crisis and will provide insights that can be leveraged in other communities. This webcast features Healthbox and PCCI leaders:

Please have a look at the full set of HIMSS Webcasts featuring PCCI and Healthbox discussing how to implement SDOH principles via connected communities of care:

 

 

27 October 2020

PCCI’s Vulnerability Index observes uptick COVID-19 risk in Dallas County, as hot spots re-emerge




DALLAS – As of October, Parkland Center of Clinical Innovations’ (PCCI) Vulnerability Index continues to observe increases in vulnerability to COVID-19 infection in Dallas County, with several hot-spots showing a significant increase in their Vulnerability Index (VI) .

 

Figure 1: Dallas County ZIP codes with the highest vulnerability values.

Launched in June, PCCI’s Vulnerability Index determines communities at risk by examining comorbidity rates, including chronic illnesses such as hypertension, cancer, diabetes and heart disease; areas with high density of populations over the age of 65; and increased social deprivation such as lack of access to food, medicine, employment and transportation. These factors are combined with dynamic mobility rates and confirmed COVID-19 cases where a vulnerability index value is scaled relative to July 2020’s COVID-19 peak value.

The Vulnerability Index reports that in early October (See Table 1), the ZIP Code with the highest vulnerability value continued to be 75211, around Cockrell Hill. This area has been a high-risk area since the launch of PCCI’s Vulnerability Index.

Other ZIP codes of note include the area in 75228, which has risen from the sixth most at risk zone in July to the second most as of October. The ZIP code, 75204, is now the seventh most at-risk zone, after being outside the top ten in July. Additionally, the ZIP codes, 75240 and 75243 both dropped out of the top ten most vulnerable ZIP codes as of October.

PCCI’s Vulnerability Index also found that the top five most vulnerable ZIP codes showed the most extreme increases (See Table 2); the next five had growth but remain at a moderate Vulnerability Index levels. Contributing to vulnerability rating for all ten ZIP codes was increased year-over-year mobility that was detected. COVID-19 case counts have also increased generally across the county.

“The ways to fight this virus remain the same as prior months – limit outside visits,

wash your hands regularly and thoroughly with soap, wear a mask when travel is required outside the home, and continue social distancing,” said Thomas Roderick, PhD, Senior Data and Applied Scientist at PCCI.  “Also, be sure to listen to public health authorities, such as the Dallas County HHS, Texas DSHS, and CDC. Working together we can push back against the recent increase in cases.”

Figure 2: Dallas County ZIP codes by increase in Vulnerability Ranking change.

The PCCI COVID-19 Vulnerability Index can be found on its COVID-19 Hub for Dallas County at: https://covid-analytics-pccinnovation.hub.arcgis.com/.

Data Sources:

To build Vulnerability Index, PCCI relied on data from Parkland Health & Hospital System, Dallas County Health and Human Services Department, the Dallas-Fort Worth Hospital Council, U.S. Census, and SafeGraph.

About Parkland Center for Clinical Innovation

Parkland Center for Clinical Innovation (PCCI) is an independent, not-for-profit, healthcare intelligence organization affiliated with Parkland Health & Hospital System. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations. We believe that data, done right, has the power to galvanize communities, inform leaders, and empower people.

 

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27 October 2020

PCCI’s COVID-19 Animated Heat map Shows Dallas County’s Infection Evolution




Below is the PCCI’s COVID-19 animated heat map that shows the infection spread in Dallas County beginning on March 9, 2020 and ending on October 18, 2020, using Dallas County Health & Human Services Department’s COVID-19 confirmed and presumed case data. The animated geomap includes hot spots, indicated in orange, of cases over 14-day periods.

The underlying map (purple highlights) is PCCI’s Vulnerability Index updated with COVID-19 cases and SafeGraph mobility data as of October 19, 2020. Dallas County Jail and Federal Bureau of Prison locations excluded from the visualization.

Go to PCCI’s COVID-19 Hub to track cases, see the new Vulnerability Index and heat maps in Dallas County at: https://covid-analytics-pccinnovation.hub.arcgis.com/

26 October 2020

PCCI Recognition: CEO Steve Miff honored as a Most Inspiring Leader by Dallas Business Journal




As a reflection of the outstanding efforts PCCI has conducted battling the COVID-19 outbreak in Dallas, the Dallas Business Journal has honored Steve Miff, as a representative of PCCI, for its “2020 Most Inspiring Leaders” award. The awards honor companies and corporate leaders from the North Texas-area representing different sized companies from a number of industries who helped lead efforts to combat the pandemic.

Click this link to see a slide show of all DBJ’s honorees:

https://www.bizjournals.com/dallas/gallery/472954

PCCI’s efforts will be recognized at a virtual reception on Thursday, November 19th from 4:00 – 5:15 p.m.

Register your team to receive a complimentary set of “Building Connected Communities of Care” and kick off your Executive Book Club with a consultation from one of our experts.

Register your team to receive a complimentary set of “Building Connected Communities of Care” and kick off your Executive Book Club with a consultation from one of our experts.

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