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13 September 2022

VIDEO: Managing the Dallas Accountable Health Communities Model

This video features PCCI’s CEO Steve Miff and Jacqueline Naeem, MD, Senior Medical Director/Program Director AHC, discussing the successful management of the Dallas Accountable Health Communities Model as detailed in the recent New England Journal of Medicine article.

Click here to watch the video: https://www.youtube.com/watch?v=IvGHgZGEU1Q

13 September 2022

New England Journal of Medicine Catalyst: PCCI’s Know Thy Patient Program Helps Better Understand Patient Populations

New England Journal of Medicine Catalyst:

Know Thy Patient: A Novel Approach and Method for Patient Segmentation and Clustering Using Machine Learning to Develop Holistic, Patient-Centered Programs and Treatment Plans

By integrating and analyzing metrics associated with barriers to health care access — social vulnerabilities, transportation barriers, lack of insurance coverage — within the clinical context, Parkland Health leaders will be able to better understand the community and patient population they serve in the Dallas–Fort Worth area.

Read the full article here:



24 August 2022

Inside the New England Journal of Medicine Catalyst Article on PCCI’s Successful Management of the Dallas Accountable Health Communities Model

The globally recognized leader in healthcare publishing, the New England Journal of Medicine Catalyst (NEJM Catalyst), has distributed an in-depth article authored by PCCI detailing its successful journey managing the U.S. Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Model in Dallas County1.

To view the NEJM Catalyst article, click here: https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0149

The NEJM Catalyst article offers the results of this five-year initiative, which included partnerships with the region’s top healthcare providers and community-based organizations (CBOs), that demonstrates its positive impact on health care outcomes for some of the most vulnerable Dallas County residents.

The peer reviewed NEJM Catalyst article outlines the purpose of the AHC Model in testing whether systematically identifying and addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSN), i.e., food, housing, transportation, utilities, and interpersonal safety, through screening, referral, and community navigation services impacts total health care costs and reduces inpatient and outpatient utilization.

The article further describes how bridge organizations (such as PCCI) served as ‘hubs’ in their communities, forming partnerships with their state Medicaid Agencies, local clinical delivery sites, and CBOs. The Dallas AHC (DAHC) included five major healthcare systems (Parkland Health, Baylor Scott & White, Children’s Health, Methodist Health System, and Metrocare Services), Texas Health and Human Services Commission (TX HHSC), and more than 100 CBOs who provided critical social services to meet the needs of residents in Dallas County ZIP codes with high concentrations of unmet HRSN.

Written by PCCI clinical experts and leaders of all aspects of the DAHC, the NEJM Catalyst article offers a comprehensive look at the full five-year initiative in Dallas and its impact on HRSN, utilization, and costs. This analysis includes critical details (and lessons learned) in the DAHC’s planning and implementation as well as methodology, results, and a look forward.

“We are so proud of the opportunity to lead such a meaningful initiative in partnership with CMS, TX HHSC, our participating healthcare systems, and the hundreds of other North Texas organizations who participated. The innovations, learnings, and results are invaluable and can hopefully serve as a blueprint for expanding these efforts regionally and even to other markets in our collective journey to address the social and personal determinants of health of our most vulnerable families,” said Steve Miff, PCCI’s CEO and President. “The significant number of individuals screened and navigated could not have been possible without the amazing support of the hospital systems and many CBOs in Dallas that actually delivered services to the people who came through the DAHC. This article shows the true scope and community-wide effort that makes programs like this successful.”

The NEJM Catalyst article, co-authored by PCCI’s Jacqueline Naeem, MD, Estefania Salazar-Contreras, Venky Sundaram, PhD, Leslie Wainwright, PhD, Keith Kosel, PhD, and Miff, provided strong evidence of the benefit of addressing HRSNs in a comprehensive manner using active navigation within the framework of a connected community of care model that coordinates efforts between clinical and community services.

“The NEJM Catalyst article digs deep into what our challenges were and the steps we took to test how addressing HRSNs improves utilization and health of vulnerable populations,” said Leslie Wainwright, PhD, PCCI’s Chief Funding and Innovation Officer. “Because of the tremendous effort and success we had in identifying, screening, and navigating so many individuals, this article is able to show some clear, thought-provoking results that will give us a logical path forward as we seek ways to address the needs of those most at-risk in our communities.”

The article reports that during the initiative’s five-year course, PCCI and its partners screened 12,548 individuals and identified more than 19,000 distinct needs, with 61% of individuals having two or more concurrent needs. Through the referral process, CBOs provided a multitude of support services, including more than 200,000 pounds of food and $540,000 in utility and rent assistance.

Additionally, the article shows that actively navigated individuals experienced a greater decrease in per-person ED visits.

“This was a tremendous project that garnered some exciting results, which is why the NEJM Catalyst article is so important for sharing how communities can make this work,” said PCCI’s Jacqueline Naeem, MD, Senior Medical Director/Program Director AHC. “But while the article shows important results, this is about more than just data, this is about the people in need who benefited substantially from the screenings, navigations, and participation in the initiative. The stories we heard of the lives we touched during the five-year program is a lasting legacy of the work our entire community put forward.”

In addition to the DAHC work and with the goal to help other municipalities build their own connected communities of care, PCCI also published an in-depth guidebook, “Building Connected Communities of Care.” This is the definitive guide for taking action using social determinants of health, with practical actionable insights from PCCI’s experience building, deploying, and expanding a connected community of care in Dallas. For more information on “Building Connected Communities of Care,” click here: https://pccinnovation.org/playbook/


[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.

18 August 2022

New England Journal of Medicine Catalyst: The Dallas Accountable Health Community – Its Impact on Health-Related Social Needs, Care, and Costs

The New England Journal of Medicine/Catalyst published a paper by PCCI on the challenges and successes during the Parkland Center for Clinical Innovation’s 5-year involvement in a federally supported study of care delivery efforts to address #SDOH through community collaboration and patient navigation:

Click here for the full story: https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0149

17 August 2022

Parkland, PCCI recognized for health technology innovation; Receives first Davies Public Health Award from HIMSS since 2012

DALLAS – Parkland Health, in collaboration with Dallas County Health & Human Services (DCHHS) and Parkland Center for Clinical Innovation (PCCI) announced they have earned the 2022 Public Health Davies Award from the Healthcare Information and Management Systems Society (HIMSS). The award recognizes the outstanding achievement of organizations that have utilized healthcare information and technology to substantially improve patient outcomes and value within the public health arena. The collaborative group is the first Davies Public Health Award recipient recognized by HIMSS since 2012.

“We are honored to be recognized as the first Davies public health recipient in a decade. While it is a privilege to receive this award, the most noteworthy part of this recognition is the way everyone at Parkland, PCCI and the health department comes together to care for the residents of Dallas County,” said Fred Cerise, MD, MPH, Parkland’s President and Chief Executive Officer. “This collaborative effort showcases the many innovative ways that Parkland’s use of data improves the health of our patient population and continues to advance the health and well-being of the individuals and communities entrusted to our care.”

The award application highlighted the collaboration between Parkland, PCCI and DCHHS in creating semi-automated contact tracing and the development of Proximity Initiatives which helped identify potential individuals exposed to COVID and offer resources for medical and food insecurity needs. The team built electronic case reporting between the health department and Parkland along with improved public health reporting, equitable vaccination efforts using the Parkland/DCHHS Community Health Needs Assessment, PCCI’s Community Vulnerability Compass scores and geo-mapping and hot-spotting activities throughout the county for COVID testing and vaccination efforts.

HIMSS surveyors commended Parkland, PCCI and DCHHS for using information technology in clinically meaningful ways to facilitate population health through collaboration and innovation, and in working to hardwire processes for maintaining this collaboration into the future. The award showcases the thoughtful application of health information and technology to substantially improve clinical care delivery, patient outcomes and population health.

“Just as impressive, Parkland Health’s infrastructure supports a digital capacity that addresses the wellness, public health and health-related insecurities of the 2.6 million residents of Dallas County,” said Tom Leary, senior vice president and head of government relations at HIMSS. “It is a model for digitally transforming community health, and it provides a scalable blueprint for modernizing public and community health data for the entire healthcare ecosystem.”

The HIMSS Davies Public Health Award showcases organizations leveraging information and technology to enhance core public health services (contact tracing, syndromic disease surveillance reporting, electronic case reporting, notifiable disease surveillance, vital records reporting, electronic reportable laboratory results reporting and immunization registry reporting and queries) and drive faster, more actionable intelligence to improve community health.

To learn more about Parkland services, visit www.parklandhealth.org.


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6 August 2022

DMagazine: This Locally Developed Dashboard Could Revolutionize Public Health

DMagazine features the work PCCI has contributed to the development of the Community Protection Dashboard released this week. (https://pccinnovation.org/new-covid-19-analytics-dashboards-unveiled-by-consortium-of-healthcare-and-data-experts-tracks-levels-of-protection-against-the-virus-at-the-county-level/)

Developed in a partnership between the Institute for Healthcare Improvement (IHI), Civitas Networks for Health (Civitas), Cincinnati Children’s Hospital (Cincinnati Children’s) and the Parkland Center for Clinical Innovation (PCCI), the COVID-19 Community Protection Dashboard is built from antibody prevalence surveillance, case reports, and counts of people with vaccinations series and boosters within a community.

The dashboard, available at: https://www.civitasforhealth.org/community-protection-dashboard/; offers an aggregate Community Protection Index (CPI) for nearly all of the counties in U.S. in the form of a score that combines multiple factors. These factors include the percent of the population that has received a booster dose; the percent of the population that have completed an initial vaccine series; the percent of cumulative reported cases and the percent of presumed cases.

Click here to read the full story at DMagazine: https://www.dmagazine.com/healthcare-business/2022/08/this-locally-developed-dashboard-could-revolutionize-public-health/


3 August 2022

New COVID-19 Analytics Dashboards Unveiled by Consortium of Healthcare and Data Experts Tracks Levels of Protection Against the Virus at the County Level

Data on COVID-19’s ever changing behavior and its potential impact at the county level is now available with the release of the national COVID-19 Community Protection Dashboard. Developed in a partnership between the Institute for Healthcare Improvement (IHI), Civitas Networks for Health (Civitas), Cincinnati Children’s Hospital (Cincinnati Children’s) and the Parkland Center for Clinical Innovation (PCCI), the COVID-19 Community Protection Dashboard is built from antibody prevalence surveillance, case reports, and counts of people with vaccinations series and boosters within a community.

The dashboard, available at: https://www.civitasforhealth.org/community-protection-dashboard/; offers an aggregate Community Protection Index (CPI) for nearly all of the counties in U.S. in the form of a score that combines multiple factors. These factors include the percent of the population that has received a booster dose; the percent of the population that have completed an initial vaccine series; the percent of cumulative reported cases and the percent of presumed cases.

The county-level CPI and core factors are available using a mouse-over interface on the dashboard’s map. The CPI is the score each county is given showing its population’s level of COVID-19 protection. A perfectly protected community would have a theoretical max score of 100. Currently observed national rates show an average CPI of 51.6. Nationally, the CPI range is between 41 to 83, showing a tremendous variation on the county-level. For example, Los Angeles County, Calif., that has a CPI of 70 based on its population being boosted, with 73 percent having completed its initial vaccine series as well as 30 percent reported infections and 63 presumed to be infected. Compare this to Fulton County, Ga., that reports a CPI of 59, due to lower boost percentage, 47, completed vaccination series, 47 and 20 percent reported cases and 73 percent presumed infections.

Dallas County has an overall index of 60, with 39% of population boosted.

“The goal of the analytics within the dashboard is to contextualize what it’s being observed locally to what is happening concurrently across surrounding counties, state and nation,” said Steve Miff, PhD, CEO and President at PCCI. “We intend for these insights to help provide a local dynamic vulnerability awareness with a national contextualization and use it to help identify emerging trends and forecast impact based on cross –region comparisons. Local cross-county/region collaboration and communication can also be enhanced with these additional insights.”

The collaboration of these healthcare and data analytics organizations has developed the dashboard with the goal of bringing together multiple sources of readily available COVID data and interpreting the information into a consistent and digestible way, including:

  • Taking into account the strong immunity from recent vaccination, but factoring the impact of waning immunity over time and the characteristics of the most recent variant
  • Weighting the extra protection from booster vaccination against new variants
  • Acknowledging the contribution from nature immunity
  • Including estimates of hybrid immunity

“There is a correlation with the CPI and recent hospitalization population rates, but the application is not a predictive model, it is a tool to foster community awareness that protecting a community from serious comorbidity and systemic stress on hospitalization requires vigilance,” said Dr. Holt Oliver, PCCI’s Vice President of Medical Informatics. “Even though the seroprevalence of protective antibodies is in the high 90%, as we go in to our first fall and winter infectious season with protection that for many Americans is waning, the value of continuing this conversation will be increasingly important.”

This effort has been part of a larger initiative led by IHI with its lead partner, Civitas.  In Phase 1 of the initiative, the IHI-led team implemented a rapid innovation cycle to learn from early experiences, scan emerging best practices and challenges, and develop a model for mounting a rapid local response to the U.S. vaccine crisis. Initial research conducted by IHI, The Health Collaborative, PCCI/Parkland Health and Cincinnati Children’s produced a vaccine implementation and delivery model as well as a set of change theory ideas for testing and scaling vaccine distribution in defined local populations.

In Phase 2, the initiative engaged in qualitative interviews with health departments and Health Information Exchanges (HIEs), which included Nebraska, North Carolina, Maryland, Texas and Indiana, to better understand how data has been used to support public health efforts during the Covid-19 pandemic. Through the work done in Phases 1 and 2, the COVID-19 Community Protection Dashboard prototype has been developed to support data sharing. A number of other deliverables and publications are in process and will be shared at various Civitas events, at the IHI Annual Conference and in upcoming journal articles and various publications.

“The availability of community-based tools, fed with local data, is key to local decision making. By mapping where pockets of vulnerability exist and how immunity likely changes over time, it becomes possible to target resources to better keep communities safe,” said Dr. David Hartley, an epidemiologist at Cincinnati Children’s. “This work illustrates how to do just that.”

About Civitas Networks for Health

Civitas Networks for Health is a mission- and member-driven organization dedicated to using health information exchange, health data and multi-stakeholder, cross-sector approaches to improve health. It was formed in October 2021 with the affiliation of the Strategic Health Information Exchange Collaborative (SHIEC) and the Network for Regional Healthcare Improvement (NRHI). Civitas Networks for Health counts more than one hundred regional and statewide health information exchanges (HIEs), regional health improvement collaboratives (RHICs), quality improvement organizations (QIOs) and all-payer claims databases (APCDs) as well as more than 50 affiliated organizations as members and reaches approximately 95 percent of the United States population. To learn more, please visit www.civitasforhealth.org.

About the Institute for Healthcare Improvement (IHI)

The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization based in Boston, Massachusetts, USA. For 30 years, IHI has used improvement science to advance and sustain better outcomes in health and health systems across the world. IHI brings awareness of safety and quality to millions, catalyzes learning and the systematic improvement of care, develops solutions to previously intractable challenges, and mobilizes health systems, communities, regions, and nations to reduce harm and deaths. IHI collaborates with a growing community to spark bold, inventive ways to improve the health of individuals and populations. IHI generates optimism, harvests fresh ideas, and supports anyone, anywhere who wants to profoundly change health and health care for the better. Learn more at ihi.org

About Cincinnati Children’s

Cincinnati Children’s ranks among the top five in the nation in U.S. News & World Report’s 2021-22 listing of Best Children’s Hospitals. A nonprofit, academic medical center established in 1883, Cincinnati Children’s is one of the top three recipients of pediatric research grants from the National Institutes of Health. The medical center is internationally recognized for improving child health and transforming delivery of care through fully integrated, globally recognized research, education, and innovation. Additional information about technologies developed at Cincinnati Children’s may be found at Innovation.CincinnatiChildrens.org

About Parkland Center for Clinical Innovation

Parkland Center for Clinical Innovation (PCCI), founded in 2012, is celebrating a decade as a not-for-profit, healthcare innovation organization affiliated with Parkland Health. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations.



25 July 2022

PCCI Promotes Capria Dees to Vice President, Talent Management & Chief Diversity Officer

Dallas, Texas – The Parkland Center for Clinical Innovation (PCCI), which is celebrating its 10th anniversary of delivering groundbreaking healthcare results that have pioneered innovation, has announced the promotion of Capria S. Dees, RN, MN, PHR, to Vice President, Talent Management. She currently serves as the Chief Diversity Officer for the healthcare non-profit.

As PCCI’s Vice President of Talent Management and Chief Diversity Officer, she serves as the human resource business partner, employee relations coordinator, recruiter, strategic business partner, Engagement Committee leader and employee immigration liaison. She is also the organization’s advocate for diversity and inclusion and has implemented numerous programs and events to progress PCCI’s mission to build a model, diverse workplace.

Dees, who has been with PCCI since 2017, has held leadership roles in talent management for the last 20 years. She began her career with Parkland Health in December 1999 as a nurse recruiter.

“Capria’s value to PCCI cannot be overstated,” said Steve Miff, PCCI’s CEO and President. “She is incredibly knowledgeable, effective and most of all, caring. She is a key leader at PCCI ensuring we attract and grow the highest quality and most diverse team. She then makes sure our culture of inclusion helps each of our employees reach their potential in a positive, innovative environment. Our organization has reached its heights of excellence thanks to the efforts of leaders like Capria.”

One of Dees’ most notable accomplishments is helping to establish PCCI’s Sach Summer Scholars, one of the most prestigious internships in North Texas. The program, which started in 2019, offers opportunities for high school and college women to be emersed in the world of healthcare technology and data science. This is a showcase program for PCCI which will have its current class of interns present their program of work on August 11.

Capria earned a Bachelor of Science degree in nursing from Dillard University in New Orleans and a master’s degree in nursing from Louisiana State University Medical Center (New Orleans). She was honored as one of DFW’s Great 100 Nurses in 2017 and holds a certification in Human Resources. She is an active member of the Society for Human Resources Management and Alpha Kappa Alpha Sorority.

 PCCI’s 10th Year Anniversary

This year, PCCI is celebrating its 10th anniversary as it continues to be one of the most important healthcare research centers in Dallas. PCCI is the winner of a D CEO 2021 Nonprofit & Corporate Citizenship Award, D magazine & Dallas Innovates’ Most Innovative Healthcare Award in 2021 and is on the D CEO magazine Dallas500 list of top businesses for 2020 and 2021. For more information about PCCI’s anniversary and how to join its efforts to expand equitable access to care, go to: www.pccinnovation.org.

About Parkland Center for Clinical Innovation

Parkland Center for Clinical Innovation (PCCI), founded in 2012, is celebrating a decade as a not-for-profit, healthcare innovation organization affiliated with Parkland Health. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations.



27 June 2022

VIDEO: PCCI Celebrates the reopening of its office

PCCI is one of the best places to work in North Texas and recently its team celebrated the reopening of it office after more than two years of dealing with the COVID-19 pandemic. Because of our culture of collaboration, the team of data science and clinical experts excelled working remotely, but this gathering was a great opportunity to meet in person, and for some, to meet for the first time. Going forward, PCCI will operate in a hybrid manner with its office serving as a resource and home-base for its team.

Have a look at the video of the office reopening here: PCCI Culture – Office Reopening

21 June 2022

ECRI Podcast: Fighting Healthcare Disparities l Equitable and Accessible Healthcare for All

This podcast episode is part of a series regarding the ECRI and the ISMP Patient Safety Organization’s (PSO) annual Deep Dive report.

The 2021 Deep Dive report focuses on issues of racial and ethnic disparities in healthcare. Research has repeatedly confirmed that members of racial and ethnic minority groups are more likely to experience disparities in care, including having an increased risk of being uninsured or underinsured, lacking access to care, and experiencing worse health outcomes for treatable and preventable conditions.

In this episode, our guests discuss their data-driven approach to identify and combat disparities and realize their vision of creating a Dallas County with equitable, accessible healthcare for all. Our first guest, Brett Moran, MD, is from Parkland Health & Hospital System, one of the country’s largest and most progressive safety-net hospitals. Our second guest, Steve Miff, PhD, is from Parkland Center for Clinical Innovation, a leading, non-profit, data science, artificial intelligence and innovation organization affiliated with Parkland Health & Hospital System.

Visit ECRI and the ISMP PSO to learn more or to request a demo. Download the executive brief of ECRI and the ISMP PSO’s Deep Dive, Racial and Ethnic Disparities in Health and Healthcare today.

Click this link to listen to this important podcast: