VIDEO: PCCI Unveils Community Vulnerability Compass, Giving Deep Insights Into the Health of Texas Communities
PCCI’s CEO, Steve Miff, PhD, and Chief Funding and Innovation Officer, Leslie Wainwright, PhD, reveal the details of PCCI’s newest innovation, the PCCI Community Vulnerability Compass. The CVC can help virtually any Texas-based organization (hospital system/health plan, care provider, CBO, public health entity, philanthropic funder, etc.) seeking to understand not only where its community’s most vulnerable residents live but also many of the underlying, multi-dimensional root cause factors driving these residents’ poor health and healthcare access and ability to thrive. Through a fuller understanding of these root causes, organizations can develop better programs, resources, and interventions to eliminate disparities, achieve health equity, and improve the health and well-being of vulnerable residents.
Click on the link below to view the video on PCCI’s LinkedIn page:
PCCI’s Community Vulnerability Compass Shows Mental Health Vulnerability Highest In Economically Challenged Areas of Dallas County
The Parkland Center for Clinical Innovation (PCCI) has released an analysis of Dallas County using its cutting-edge Community Vulnerability Compass (CVC) tool that shows how economically disadvantaged areas of Dallas County are also the most vulnerable to mental health concerns.
Sections in the south and southeast areas of Dallas County, which historically have had socio-economic disadvantaged populations, are revealed to have the highest mental health vulnerability rating (“Very High”) by the CVC. The “Very High” designation indicates that these areas are in the top 20 percent of vulnerability, when compared to the rest of Dallas County.
“In addition to poor mental health, these areas also have some of the lowest life expectancies and highest density of chronically ill populations in the County,” said Steve Miff, PhD, CEO and President of PCCI. “Just like our bodies need preventative care to optimize our physical health, our minds need the same attention to improve our mental health. There is also a strong correlation between your environment and both mental and physical health. In fact, these are tightly interwoven, where poor physical health can negatively impact mental health, and poor mental health can adversely impact physical health. We at PCCI believe that efforts to improve health must address the whole person. To lift the health of our community, you can’t focus solely on chronic diseases, but must also concurrently tackle mental health and address life barriers to access resources, especially in the most at-risk neighborhoods.”
The CVC is designed to help Texas-based organizations seeking to understand (at a county, ZIP code, census tract, or block-group level) not only where its community’s most vulnerable residents live but also many of the underlying, multi-dimensional root cause factors driving these residents’ poor mental and physical health and ability to thrive. The CVC tool includes 26 clinical and socio-economic indicators that reveal the health, resiliency, and economic vibrancy of neighborhoods.
PCCI’s CVC measures mental health by analyzing CDC data on the number of adults 18 years and older who stated that their mental health, which includes stress, depression, and problems with emotions, was not good for 14 or more of the last 30 days. The CVC also analyzes economic, education, safety, environmental, and other diverse health and social indicators to create a full picture of the County’s community health, as well as community health across the entire State.
“As a start, these data can be extremely useful for community action groups, charities, or healthcare organizations to target education/information about mental health to these high vulnerability block groups. Although this map only highlights those 18 and older, we know caregivers’ mental health affects the children they are caring for, so organizations can also consider supporting schools in these areas. Sharing resources, teaching people about how to recognize when someone around them is struggling and promoting activities that encourage improving mental health are things that each of us can do,” said Jacqueline Naeem, MD, Senior Medical Director at PCCI.
Dr. Naeem added that the CVC’s analysis includes a wide range of data points, providing a true, holistic picture of who needs the most help and where to find them. The data PCCI provides is based on the best, most currently available information, which serves as a powerful tool to allow for proactive support of those in need.
“There is still stigma that exists around mental health, and mental illness that we need to work together to overcome,” said Dr. Naeem. “This data allows us to focus on the whole person by concurrently addressing the physical and mental needs of our neighbors and identifying their local barriers to access services. In doing so, the location and type of services can be tailored in ways that are more convenient for the recipients and education can be hyper-localized and tailored to those recipients in a more culturally empowered way.”
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.
This Spring, HIMSS (Healthcare Information and Management Systems Society), a global thought leader and member-based society committed to reforming the global health ecosystem with information and technology, offered several platforms for PCCI’s experts to share their innovative programs with thousands of healthcare IT professionals.
PCCI in collaboration with leaders from Parkland Health, Parkland Community Health Plan and Dallas County, have delivered eight presentations, four at the national HIMSS conference in Chicago and four at the Texas HIMSS regional conference in Dallas. These eight presentations highlight the impactful and diverse applications of artificial intelligence and social determinants of health in clinical and populations health programs.
These presentations include:
HIMSS Annual National Convention:
“ML-AI-Driven Community Coalition, Digital Outreach Improves Asthma Among Low-Income Children”
Teresita Oaks, MPH, Director of Community Health Programs, Parkland Health
Description: PCCI partnered with Parkland Health to develop a Machine Learning/Artificial Intelligence asthma risk prediction model, using diverse social and clinical data sources to identify rising risk for asthma-related ED visits/hospitalizations among low-income children with asthma. Monthly risk-reports were leveraged to develop a multidisciplinary coalition across six high-asthma-morbidity Dallas County zip codes, for communitywide interventions.
“Using Data-Driven Insights to Prioritize Programs Addressing Social Vulnerabilities”
Natasha Goburdhun, MS, MPH, Vice President, Connected Communities of Care, PCCI
Paula Turicchi, FACHE, Chief Strategy Officer at Parkland Community Health Plan
Description: Despite the increasing awareness of the importance of social determinants of health (SDoH) and their influence on health outcomes, few organizations have adequate, contextualized insights to better address interrelated, social needs across a community. This presentation demonstrated how the Parkland Community Health Plan leveraged a three-tiered strategic analysis of SDoH and patient-level data to identify and prioritize programs to meet their members’ social needs.
“Integrating Universal Suicide Screening in EMR Improving Detection of Risk”
Jacqueline Naeem, MD, Senior Medical Director/Program Director AHC, PCCI
Kim Roaten, PhD., UT Southwestern Medical Center
Description:
In 2015, a universal suicide screening program was implemented at Parkland Health in which all patients 10 and older are screened for suicide risk during every provider encounter. Analysis was completed on over 3 million unique patients to understand the distribution of levels of risk in the population, as well as insights around the impact of the pandemic on patients identified with suicidal ideation.
“Patient Segmentation and Clustering Using ML to Develop Holistic, Patient Programs and Treatment Plans”
Yusuf Tamer, PhD, Senior Data and Applied Scientist, PCCI
Albert Karam, MS, MBA, Vice President, Data Strategy Analytics, PCCI
Brett Moran, MD, Chief Medical Informatics Officer, Parkland Health
Description:
In close collaboration with Parkland, PCCI developed a novel, advanced analytics process called Know-Thy-Patient (KTP) to group patients other than by their primary disease or diagnoses (e.g., diabetes, hypertension). By integrating and analyzing metrics associated with barriers to health care access — social vulnerabilities, transportation barriers, lack of insurance coverage — into the clinical context, health strategies adopting these cohort-similarity approaches can more readily incorporate a wider variety of patient-centered, whole-person approaches to care, such as integrated practice units, targeted digital programs, virtual and in-person support groups, and focused outreach and communication.
HIMSS Texas Regional Conference
“AI-Driven Interventions Improve Preterm-Birth Among Medicaid Pregnant Members” PCCI’s Yolande Pengetnze, MD, VP Clinical Leadership joins Amrita Waingankar, MD, MBA, Senior Medical Director at Parkland Community Health Plan to share how they successfully implemented preterm birth prevention program in Dallas.
“Predicting Mortality of Trauma Patients” PCCI’s Albert Karam, Vice President of Data Strategy and Analytics presents with Parkland’s Adam J. Starr, MD, will discuss this innovative predictive trauma model.
“Data Driven Approach to Addressing Health Related Social Needs (HRSN)” PCCI’s Jacqueline Naeem, MD, Medical Director will present with Vidya Ayyr, MPH, CHW, Director Social Impact at Parkland about the Accountable Health Community model recently and successfully completed in Dallas.
“Implementing Inpatient Sepsis Early Prediction Model” PCCI’s Yusuf Talha Tamer, PhD, Principal Data and Applied Scientist, will present with Parkland’s Nainesh Shah, Hospital Physician, DMIO, will share how their predictive sepsis model is changing how sepsis can be addressed.
An interactive tool to navigate SDOH-based needs of vulnerable populations
The CVC is a web-based tool enabling its users to visualize and more fully understand the context and complexities of the social barriers to health, access, and well-being of a community’s most vulnerable populations.
Based on the Healthy People 2030 framework seeking to achieve health equity, eliminate disparities, and promote good health for all, the CVC includes 26 clinical and socio-economic indicators clustered into four thematic domains denoting the health, resiliency, and economic vibrancy of neighborhoods.
Through a user-friendly dashboard, individuals can view which indexes, subindexes, and indicators are impacting vulnerability. They can utilize the dashboard’s dynamic online mapping feature, tabulated scores of indicators, and detailed analytics around other attributes that may affect vulnerability scores (e.g., race/ethnicity and demographics).
Key Features of the CVC
• Information can be visualized at the county, ZIP code, census tract, and block-group levels, giving users both a “forest and trees” view of a community. Intended to serve as a more detailed complement to other research studies (e.g., Community Health Needs Assessments) and field-based community voice initiatives, the CVC provides a comparable, data-driven summary of insights about community vulnerabilities.
• Users can also drill down to ask a series of follow-up “why” questions to really understand the root causes of inequities–a capability that is absent from other available tools.
• Insights provided by the CVC enable users to more effectively and efficiently prioritize, plan, and deploy–in a hyper localized way–supportive resources and interventions targeted to individuals or populations to advance whole-person health.
Vulnerable populations are groups of individuals (e.g., racial and ethnic minorities, the economically disadvantaged, those with chronic health conditions) who are at greater risk of poor health and well-being due to significant health and healthcare disparities (i.e., physical, economic, and social inequities). Their health and healthcare needs are most heavily driven by socio-economic, or social determinants of health (SDOH), factors such as lack of education, language barriers, and difficulty in accessing care (e.g., transportation barriers, absence of internet connectivity, deficiency in insurance coverage). However, assessing, understanding, and addressing these SDOH issues is not a simple or straightforward process for any organization seeking to improve the health of these residents. Specific unmet needs include:
• The need to look across SDOH factors to gain a holistic picture. For individuals facing high vulnerability, rarely is there only one issue they are facing; they often have multiple, complex needs. In addition, language and cultural barriers, issues with health literacy, and the organization’s own lack of resources all work against obtaining this understanding (e.g., through individual interviews) for the required number of individuals and frequency needed for impact.
• The need for a shared language across communities. In addition, evidence continues to mount that an upstream, cross-sector approach to health can result in more positive, sustainable health outcomes. A broad, community-based approach focusing on societal conditions, disruption of structural barriers (e.g., cross-sector silos), and targeted risk-driven interventions for collective impact can more effectively and sustainably remove health inequities and transform a person’s quality of life and health outcomes. However, organizations across communities use disparate data sources and different measure sets, meaning there is a lack of standardization needed to efficiently build needed cross-sector networks, create a common starting point, and effectively evaluate progress over time.
• The need to have the means to conduct root cause analyses. While there are a number of publicly available indexes that measure vulnerability, there are few that enable the root cause analyses needed to effect lasting change (i.e., showing the specific SDOH factors that are most impacting vulnerability in any given block group at any given time).
CVC addresses all of these needs and is rapidly becoming the go-to resource for teams addressing the needs of vulnerable populations.
CVC Is Built for both Clinical and Community-Based Organizations
The CVC can help virtually any organization (hospital system/health plan, care provider, CBO, public health entity, philanthropic funder, etc.) seeking to understand not only where its Community’s most vulnerable residents live but also many of the underlying, multi-dimensional root cause factors driving these residents’ poor health and healthcare access and ability to thrive. Through a fuller understanding of these root causes, organizations can develop better programs, resources, and interventions to eliminate disparities, achieve health equity, and improve the health and well-being of vulnerable residents.
CVC is an extremely useful tool for health systems and health plans who have made a commitment to community-based programming and need data-driven insights to support contemplated strategic objectives (e.g., new clinic locations). CVC insights can provide critical, contextualized information to guide these organizations and help them prioritize strategic imperatives.
CVC is especially useful for providers who have made commitments around addressing SDOH. Given the Health Systems/Health Plans with increased focus on SDOH difficulty in capturing this information directly from patients, the CVC can serve as a proxy to understand the block level of factors affecting individuals and their families. This information can also help providers design holistic programs to more effectively address the complex needs of their patients, particularly with respect to barriers to healthcare access. For example, grouping diabetic patients into diabetes program cohorts with other patients who have high degrees of similarity across clinical, personal, and behavioral characteristics can facilitate stronger provider-to-patient and patient-to-patient connections and support.
Delivering Impact
Organizations are successfully and innovatively leveraging the CVC to improve health and well-being across communities. Examples of current uses of CVC delivering impact include:
• In addition to a CBO’s use of CVC to identify areas of high vulnerability and root causes of needs across a community, the CBO is integrating its own outcome measures/goals (e.g., greater health insurance coverage across its region of service) into the CVC and tracking progress (through KPIs) over a multi-year timeframe.
• As part of an upstream, community-wide program to improve pediatric asthma in high-risk neighborhoods, organizational stakeholders are leveraging the CVC to identify rising risk for asthma-related Emergency Department (ED) visits/hospitalizations among low-income children with asthma.
CVC is also integrated into the design of a single, community-wide, data-driven surveillance system to track and monitor pediatric asthma at the community, neighborhood, and individual levels. This will improve the capacity of community stakeholders (including providers) to incorporate upstream, contextual SDOH factors and other important data into local policies, programs, and interventions to prevent ED visits and hospitalizations, close the asthma disparity gap, and meaningfully evaluate the impact of these efforts on the long-term health outcomes, quality of life, and care experience of children with asthma (and their families).
• Through use of patient-specific data via electronic health records (EHR) and SDOH data via the CVC (as a proxy for individual data), a health system is grouping patients by their access and utilization of healthcare resources rather than by disease group in order to more fully understand access barriers of patient cohorts and their utilization patterns. The goal is to improve patient healthcare access by supporting and informing better design of clinical programs that enable new community partnerships and enhanced models for patient engagement, such as expansion of virtual engagement options.
• A provider is using CVC SDOH insights (e.g., transportation challenges, internet connectivity, access to vital services) to determine, among other things, optimal locations for new community clinics serving vulnerable populations with advanced healthcare access issues.
• A health system and health department are analyzing (via side-by-side dashboards) CVC SDOH data and chronic disease data to better understand the specific SDOH factors impacting disease prevalence and then design and drive improved care programs to that cohort.
Methods
The CVC Leverages Curated SDOH Data to Create Normalized, Comparable Insights
While the ideal state is to hear about SDOH challenges directly from the affected individuals, it isn’t feasible to obtain this information at scale across communities. However, through research we know that SDOH factors are personalized to neighborhoods and this information can serve as a reasonable proxy for individual specifics, as characteristics of a resident’s block (e.g., transportation challenges, lack of green space) closely represent the challenges that resident likely faces.
The CVC groups levels of vulnerability for each of its four subindexes and 26 indicators into quintiles from lowest to highest vulnerability (i.e., very high, high, moderate, low, very low). Users can identify and create a visual map of where targeted individuals reside, study the characteristics of their neighborhoods and underlying barriers to health (ranked highest to lowest) based on location, and then prioritize individual or community-based service support. At the geographic level, the CVC captures data with increasing granularity from the county, ZIP code, census tract, to the block-group level. Users can view the 26 specific clinical and SDOH factors clustered by theme across the four subindexes aligning with the Healthy People 2030 framework. The subindexes include Household Essentials (e.g., food insecurity, paycheck predictability, health insurance coverage), Empowered People (e.g., mobility, internet connectivity, education), Equitable Communities (e.g., employment, housing, green space), and Good Health (e.g., chronic diseases, life expectancy, mental health). The CVC provides a score (Community Vulnerability Index/CVI) based on vulnerability for each individual indicator, aggregated factors across each of the four CVC subindexes, and a “rolled-up” single score across the targeted geographic area.
For its users, the CVC also provides a standard, single source of accurate, in-depth, real-time data that they can access, understand, disseminate, and act upon to ensure the most effective, coordinated, evidence-driven programs and the best possible health outcomes. Through the CVC’s four subindexes and 26 clustered indicators, provider and community-support networks can have a common starting point from which to incorporate SDOH factors and other important data into programs (e.g., reduction in pediatric asthma) that operate further upstream to close disparities gaps and advance health equity. And through a common evaluation framework, these networks can quantify the impact of interventions against the changing SDOH dynamics across a community in both the short-term (e.g., reduction in readmissions) and in the longer-term improvements in health outcomes.
Depending on their specific use cases and programming, organizations need access to different levels of geographic specificity. The CVC allows users to view its subindexes (and the composite indicators) at the county, ZIP code, census tract, and block-group levels. This flexibility to zoom up or down, depending on the use cases, allows users to more effectively address their unique challenges, especially given their finite resources.
In collecting the data from multiple data sources for the CVC, PCCI goes through a rigorous cleansing and quality assurance (QA) process to ensure the input data is complete and more robust than what users would obtain from publicly available websites. For example, PCCI uses data-science approaches to fill in missing values (e.g., computing a score based on averaging the values of the three closest neighborhoods). We also make needed QA adjustments, such as excluding those of retirement age when calculating unemployment or including both rental- and mortgage-related expenses when calculating costs associated with housing. PCCI has also validated the CVC against the gold standard Area Deprivation Index (ADI) and the CDC’s Social Vulnerability Index (SVI) to ensure the CVC is directionally aligned with other commonly used sources. Although the ADI is a well-known, powerful tool in capturing community need across a number of factors, it does so in the aggregate and does not enable users to drill down to the level of specificity needed across individual factors to more effectively inform the best, most holistic program or intervention design. Conversely, other tools such as the SVI do allow users to drill down for specificity across included factors but those factors don’t encompass the broader CVC range of risk factors impacting a community’s health. For example, the SVI factors focus on the attributes relevant to its purpose in planning for public health emergencies. While the CVC and SVI include some common indicators, the CVC is specifically designed, through its alignment with the Healthy People 2030 framework, to focus on the wider range of specific, actionable neighborhood risk factors known to influence the health of vulnerable populations.
Finally, the CVC allows for integration—using the existing CVC dashboard—of a user’s existing data to create new, custom indexes or models. For example, if an organization is tracking particular metrics for readmissions reduction, those metrics can be integrated into the CVC and tracked over time along with the existing CVC subindexes/indicators.
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To download a PDF of the CVC Information Sheet, use the following:
A deeper dive into Steve’s position that in order to effectively deploy value-based care and sustain it, we have to focus on health in addition to healthcare.
Identifying the first steps organizations need to take to begin building out healthcare data analytics and social infrastructure, and what the biggest challenges are along that path.
How data can be leveraged for the social determinants of health?
When will organizations move beyond population-level social determinant data and move into personalized referrals?
What excites Steve about the future of healthcare and specifically value-based care?
What is on the horizon at PCCI in this time of change in healthcare?
PCCI has released its 2022 Annual Impact Report virtually. PCCI’s 2022 Annual Impact Report outlines PCCI’s efforts over the past year to help support those most in need in our communities.
The report includes insights into PCCI’s innovations including PCCI’s efforts to fight COVID-19 in Dallas the conclusion of the Accountable Health Communities Model in Dallas County, pediatric asthma mitigation, preterm birth prevention and much more.
Read a presentation abstract, co-authored by PCCI’s Steve Miff, that highlights the evolution of PCCI’s COVID-19 vulnerability index to the nationwide Community Protection Index.
Abstract
Background The COVID-19 pandemic has highlighted the critical and ongoing need for leaders across health care, public health, and government to have real-time, hyper-local data. These data need to be relevant and meaningful across multiple sectors. Moreover, data are most likely to be useful when they facilitate connections across systems, enable situational awareness, and drive equitable decision making.
Other authors of the presentation include members from the Institute for Healthcare Improvement, PCCI, Cincinnati Children’s Hospital and University of Cincinnati College of Medicine, and Civitas Networks for Health.
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:
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.
PCCI has released its 2022 Annual Impact Report virtually. PCCI’s 2022 Annual Impact Report outlines PCCI’s efforts over the past year to help support those most in need in our communities.
