For more about PCCI’s 10 years of pioneering new ways to health, go to: 2022 PCCI Annual Impact Report
For more about PCCI’s 10 years of pioneering new ways to health, go to: 2022 PCCI Annual Impact Report
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/
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[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.
Following is an excerpt from PCCI’s book, “Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations.” This is a practical how-to guide for clinical, community, and government, population health leaders interested in building connected clinical-community (CCC) services.
This section is from Chapter 7, “Community Partners Track.” The Community Partners Track provides the requirements for the workflows and the tools needed for Community-Based Social Service Organizations aka Community-Based Organizations (CBOs) to achieve the goals of the Connected Communities of Care (CCC).
PCCI offers readiness assessments as a service for those organizations interested in building an SDOH-based CCC. Go here for more information: https://pccinnovation.org/connected-communities-of-care/.
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Case Study: Building CBO Partnerships
A cornerstone of the CCC is the CBO. The community food pantries, homeless shelters, crisis centers, and transportation service providers are the lifeline for many vulnerable and underserved community residents. In addition to providing essential services, these organizations help the individuals cope with the challenges of daily life. For far too long, these organizations were excluded from the clinical care plan process for a host of reasons. Communities Foundation of Texas (CFT) (the initial philanthropic funder of the Dallas Information Exchange Portal [IEP]) and PCCI recognized the vital role these entities play in the health and well-being of the individuals seeking care at Parkland.
As part of the design of the Dallas IEP, PCCI began an ongoing effort to establish meaningful partnerships with local CBOs to foster their involvement in (and support of) the Dallas IEP, through linkages to each other and to Parkland. PCCI recognized early on that given the large geography covered by Dallas County, more than a couple CBOs would be needed to make the IEP robust and meaningful. In the past, efforts to engage CBOs typically involved recruitment at the individual CBO level, something that in the case of the IEP would likely prove problematic given the number needed. Instead, the PCCI team, with support from CFT, proposed a new approach of engaging the major
Sponsors of the CBOs, which in this case included the North Texas Food Bank (NTFB), which worked with many local food pantries, and the Metro Dallas Homeless Alliance (MDHA), a large umbrella organization coordinating services for dozens of smaller homeless shelters. By working directly with these umbrella organizations, PCCI only needed to execute two contracts rather than multiple contracts with the individual CBOs. The NTFB and the MDHA were then responsible for recruiting their members in sufficient numbers to increase the IEP’s scale.
While this approach proved successful, it did not remove the need for PCCI to “make the case” for the IEP with the NTFB and the MDHA. In addition to explaining how this program would involve NTFB’s food pantries and MDHA’s homeless shelters, it was imperative to make the business case for their involvement—how will this work benefit them and their members and what will be needed from the membership. In addition to helping improve the health and well-being of community residents, we found the following to be key incentives for CBO participation: (1) ability to provide funding to support the IEP or its usage, (2) enhanced reporting and analytic capability— either through the technology platform software itself or through PCCI analytical staff, (3) opportunity to participate in future research projects that would bring visibility to other sources of funding, and (4) greater operational efficiency.
Once the list of participating CBOs was shared with PCCI, the team installed the software at the participating sites, trained CBO staff, and communicated expectations and next steps. This process proved to be one of the critical success factors behind the initiative. CBO staff members that reported training as helpful and beneficial were more likely to use the IEP than those for whom training was deemed less helpful. Feedback from those receiving training suggested that two shorter training sessions (each 1.5 hours) and involving hands on practice exercises was far more helpful than one longer training session (3 hours). When PCCI staff members (1) set clear expectations of what was expected of the CBO and how the IEP was to be used and (2) reinforced that
Community Partners Track message through follow-up question and answer sessions and individual consultations, CBO use of the IEP (as it was intended to be used) was materially higher than where less emphasis was placed on expectations.
With the software installed and training completed, PCCI implemented several short pilot test periods to ensure that the technology was performing as expected and that the CBO staff felt comfortable in using it. These short pilot test periods, lasting from 2 to 4 weeks, were critical in a successful launch of the broader IEP implementation. As anticipated, the pilot work uncovered some software issues that needed to be addressed to ensure optimal use by the CBOs. The work also revealed some modifications to the CBO and clinical/CBO workflows that needed to be made. It is important to note that
all pilot testing was done without involving any patients or residents in the testing phase.
While the preparatory work helped to ensure a successful launch of the IEP both with Parkland and the participating CBOs (whose numbers grew appreciably after the launch due to continued recruitment into the network), we found that additional steps were needed to ensure ongoing success. Much like processes that are measured regularly as part of an improvement campaign and then ended abruptly when the campaign ends, we found that to optimize the effectiveness of the IEP and maintain its momentum, we needed to institute a continuous monitoring process with both the CBOs and Parkland. This ongoing involvement with the IEP Participants proved to be a greater time commitment than we had originally foreseen. While the frequency of challenges declined with the length of time since launch, we continually uncovered new issues or new opportunities to strengthen the initiative. This was especially true for the CBOs, where most staff members include volunteers and the turnover rate is quite high. Because of this, we employed a train the-trainer model, which proved largely effective. Again, most CBOs have a very small staff. Thus, the departure of a manager or experienced frontline worker often proved a major disruption to the use of the IEP. Constant contact with the CBOs (even when the number of CBO Participants approached 100) helped ensure that any challenges could be addressed as quickly and effectively as possible.
The key takeaway from the past five years of working with the CBO community in Dallas is that relationships matter, and that these relationships need constant, open and honest, two-way communication and nurturing to bring about success. We believe that these lessons apply far beyond this initiative.
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Authors:
Steve Miff, CEO and President of PCCI
Keith Kosel, Executive Advisor for PCCI
By Yolande Pengetnze, MD, MS, FAAP, PCCI’s Vice President of Clinical Leadership
What Has Everyone Excited about COVID-19 Vaccines for 5-11-year-olds?
With the rollout this month of COVID-19 vaccine for those 5-11 years of age, we can now directly protect children with asthma for whom COVID-19 infection is an even bigger hazard for our children during the pandemic.
During the COVID-19 pandemic, the term “comorbidities” has entered our daily vernacular, mostly in reference to adults’ chronic illnesses such as cancer, heart disease and diabetes, but with pediatric asthma, children and parents have their own harmful comorbidity that can be associated with life threatening COVID-19 infection. However, with the vaccinations for children now available, there is help for asthma sufferers to avoid the worst of COVID-19.
We are off to a good start. For older children in Dallas, a protective vaccine has been available for some months and, so far, more than 50 percent of high school students and more than one-third of middle/junior high students have received their vaccinations. However, we still have some ways to go. In Dallas County, many children with asthma live in zip codes with low rates of COVID-19 vaccination (Figure 1).
Figure 1. Dallas County Maps Comparing Top Zip Codes of Children with Asthma vs. Children Not Vaccinated Against COVID-19
We need to step up outreach efforts into communities with high numbers of vulnerable children to enhance vaccine education and increase vaccine uptake for children. A special focus should be directed to the top five zip codes, 75217, 75211, 75228, 75227, and 75243, that have overlapping high pediatric asthma prevalence and low COVID-19 pediatric vaccination rates. Most concerning is ZIP code 75217, located in southeast Dallas in the Pleasant Grove area, which has the highest pediatric asthma prevalence and lowest COVID-19 pediatric vaccination rate in Dallas County. Also, ZIP code 75211, in the Cockrell Hill and Oak Cliff neighborhoods, has the third highest pediatric asthma prevalence and third lowest COVID-19 pediatric vaccination rate in the county. These two ZIP codes are two of the most challenged socioeconomic areas of Dallas County and have been battered by the COVID-19 pandemic.
Help Protecting Our Children Is Here
The Pfizer COVID-19 vaccine was approved for use among 5-11-year-olds on November 2. The two-dose Pfizer vaccine is safe and effective for 5-11-year-olds at one third of the adult dose. Pediatricians, parents, schools, and other community stakeholders had been waiting for this breakthrough, especially for the benefit of vulnerable children with comorbidities such as asthma.
The COVID-19 pandemic is caused by the SARS-Coronavirus 2 (SARSCoV-2) which is primarily transmitted through airborne respiratory droplets and the most important tool in fighting respiratory pandemics is mass vaccination.
COVID-19 vaccines were developed with unprecedented speed, initially approved for adults, quickly followed by adolescents 12 years and older. As is typically, however, additional efficacy and safety studies were required for approval among children 5-11-year-olds.
Early in the pandemic, children were less impacted as the original SARSCoV2 virus strain (so-called Alpha strain) had a low transmission rate and caused mild disease among most children. As the pandemic progressed, however, the face of the pandemic evolved from a predominantly adult disease to a progressive increase in pediatric cases. Children went from representing around 4 percent of all cases early in the pandemic to accounting up to 25 percent of all cases more recently.
Contributing factors to rising pediatric cases include the emergence of highly transmissible variants (including the Delta variant, now the dominant strain in the US), in-person school reopening in the fall of 2021, relaxation of Public Health measures, reduced community mask wearing and social distancing, reopening of public spaces, and, importantly, no vaccine approval for school-age children 5-11 years old.
COVID-19 Vaccine Brings Children Needed Relief
Children 5-11 years old represent approximately 15 percent of the US population, can acquire and transmit COVID-19 in school and in the community. The absence of vaccines for this population denied them access to the most effective tool in our toolbox to fight this pandemic, making it difficult if not impossible to reach herd immunity goals of 80-90 percent community vaccination required to curb this pandemic.
Additionally, the toll of the COVID-19 pandemic among children has been rising. In 19 months since the beginning of the pandemic,
In comparison, 39,000 flu-related hospitalizations and only 366 flu-related deaths were reported among US children during the 2018-2019 flu season. The COVID-19 pediatric death toll, therefore, is ~64 percent higher than expected in a typical flu season.
Vaccines Protect Children with Asthma
Children with medical comorbidities, including poorly controlled asthma, are particularly vulnerable to severe COVID-19 infections, hospitalizations and death. Appropriate asthma control is key to mitigating COVID-19 morbidity and mortality among children.
Underlining the urgent need for vaccinating children, leading expert on pediatric asthma, Dr. Mark Clanton, Chief Medical Officer at Parkland Community Health Plan, offers clear guidance for parents with children who suffer from pediatric asthma.
“Good asthma control can be achieved through controller medication adherence, trigger avoidance, timely use of rescue inhalers, frequent follow-up with doctors, and effective use of asthma action plans at home and in school. Additionally, parents should ensure their child’s school follows pandemic prevention measures of aeration and their children assiduously follow pandemic prevention measures, including mask wearing (masks are safe and effective for children with asthma!) and physical distancing. Most importantly, parents need to their children the COVID-19 vaccine as soon as their child become eligible,” said Dr. Clanton.
The two-dose Pfizer COVID-19 vaccine, administered three weeks apart, is safe and effective for 5-11-year-olds. The vaccine elicits a strong, protective immune response and is over 90 percent effective against COVID-19 infections, hospitalizations and deaths. The vaccine likely confers protection against community spread, although data for this outcome is still forthcoming. Fewer and less severe side effects have been observed among 5-11-year-olds compared with adults. Preliminary data from the Moderna vaccine also show a similarly favorable safety and effectiveness profile.
Protect Your Children Now
With this new tool in our arsenal, we are one step closer to winning the battle against COVID-19. Vaccines, however, only work if they are administered to people who need it.
We call on all stakeholders, including parents, healthcare leaders, schools and communities to team up and make vaccines available and accessible to all eligible children. Parents, YOU are most the important stakeholders of all! We encourage you to get your elementary- middle- and high-schoolers vaccinated against COVID-19 to keep our schools safe and our community open! #GiveItAShot
(Contributors to this article include: Xiao “Michelle” Wang, PhD, PCCI Senior Data and Applied Scientist, and Steve Miff, PCCI CEO and President.)
About Yolande Pengetnze
Yolande Pengetnze, MD, MS, FAAP, is PCCI’s Vice President of Clinical Leadership where she leads multiple projects including population health quality improvement projects focusing on preterm birth prevention and pediatric asthma at the individual and the population level. Dr. Pengetnze received her MD from the University of Yaounde in Cameroon and completed a Pediatric Residency at Maimonides Medical Center in New York. She was a faculty member at UTSW’s General Pediatric Hospitalist Division where she completed a General Pediatric/Health Services Research Fellowship training and earned a Master of Sciences in Clinical Sciences.
By Keith C. Kosel, PhD, MHSA, MBA
“Show me the money!” No one old enough to have seen the 1996 movie, Jerry Maguire, will ever forget that memorable phrase. That simple but powerful phrase could apply to every person who punches a clock for a living and just about every business, including community-based organizations (CBOs) and Connected Communities of Care (CCC). For CCCs and other non-profits, a parallel but no less powerful phrase, “No margin, no mission,” also rings true― just ask Sister Irene Kraus of the Daughters of Charity National Health Care System, who is credited with giving health care the phrase. The question is, how do we satisfy these two complementary statements?
When we consider funding for a CCC, we usually speak of seed funding― those dollars provided by a grant or other type of external funding award to establish a new entity or program. Initial planning, design, development, and implementation typically fall under the heading of seed funding. But once the new entity or program is operational and the seed funding is expended, then what? How do we sustain the CCC’s operation? Unfortunately, for most non-profit organizations, that’s when they first seriously ask themselves the question, just before the money runs out and the entity and/or program is placed in immediate peril of failing. This state of hyper-anxiety could have been avoided with some simple sustainability planning initiated very early, during the initial planning phase of the project.
The time to think about how operations will be sustained is not after the entity or program is implemented, but before the first meal is served, the first patient seen, or the first service delivered. For many, especially those new to starting a going concern, this might seem like odd advice and that’s completely understandable. When you are planning, designing, developing, and implementing a new entity or program, you typically have your hands full with a myriad of activities such as hiring team members, decision-making, checking progress, and achieving milestones, revising plans, etc. The last thing you are thinking about is where to get money to keep things going, especially since you have the seed funding check in your pocket, providing a false sense of financial security. But to that initial list of must-dos, you have to include looking beyond the implementation phase to evaluate where the next paycheck will come from and how you will obtain it. To be sure, this is difficult for most organizations to do, but it is essential for the long-term viability of the entity or program like a CCC.
Before we look more closely at the two key elements of financial sustainability – 1) what funders are looking for, and 2) sources of supplemental funding― it is vitally important to state the obvious, which is that sustainability involves far more than just accessing funds. We often talk about operational sustainability, meaning those factors other than money that are essential to keep the organization functioning. Succession planning immediately comes to mind. What happens if the person leading your CCC abruptly leaves or has a major health episode (e.g., heart attack, cancer diagnosis, complications from COVID-19)? We also speak of political sustainability, such as what happens if a new administration takes office and isn’t as favorably disposed to your entity or program as the prior administration? Ever wonder why tech giants and the big Wall Street banks and brokerage firms give money to both parties? That’s political sustainability in action! While all these other types of sustainability are no doubt important, for most non-profit CBOs and CCCs, finding funds to continue operations is, without exception, their greatest concern. Because of that, I will focus my comments on financial sustainability.
Of the two key elements of financial sustainability referenced above, understanding what funders are looking for and ensuring that your new undertaking can deliver “the goods” is paramount to sustaining a CCC. Today more than ever, funders (e.g., philanthropic organizations or civic entities, including state and federal grant makers) expect organizations seeking funding for ongoing operations to be able to demonstrate―through valid, demonstrable data― that the programs and services they are delivering are making a difference. No longer are philanthropic organizations willing to simply write a check to non-profit start-ups with the admonishment to “do good with it.” Among other things, given the increasing competition among non-profits for funding assistance, funders are increasingly seeking proof that the new entity, program, or service is making a demonstrable and meaningful difference in the community or among those being served. While this certainly seems like a reasonable expectation, it often catches start-ups by surprise, setting in motion a chaotic chain reaction of panic and grasping at any funding opportunity- even if it’s not related to the core strength of the start-up, that might provide funds, and then more panic when/if that opportunity fails to materialize. To prevent this situation in your CCC, you must BOTH plan for ongoing funding and put your organization in the best possible position to demonstrate that you are making a real difference. So how do you do that? Very simply, you deliver on your promises and generate results that matter.
While that sounds simple enough, it’s what causes most new start-ups, including CCCs, to fail. Having an idea to improve the health and well-being of individuals in the community is simple, but making it happen is much more difficult. Here we are talking about ensuring you can demonstrate to potential funders that you have established realistic stretch goals and supporting objectives for your CCC or one of its programs and that you met those goals and objectives. Have you identified validated measures to track and evaluate performance and do you have a system for helping you collect and analyze the requisite data? Finally, is your program doing what you expected it to do and have you documented every step of the way? These elements are not easy to accomplish. It takes astute planning, a knowledge of the field and immediate market to know what is demanded and valued, and an obsession for tracking all the essential moving pieces. If you can do all of this and your program or service performs as expected, then you will be well on your way to securing the ongoing funding necessary to sustain your operations. As indicated, this is much easier said than done and it is where most new organizations or programs go wrong. Even when your program or service performs to perfection, failing to capture and document that performance (a very common problem among start-ups) can put you squarely behind the eight-ball.
Next, fast forward to results, which have been documented and are turning heads. This means that the funds should just start flowing in, right? Well not exactly. First, you will need to find a funder that believes in you and your data. That’s often not as difficult as it might sound. Start with those you know best― the organizations that provided your seed funding. Assuming the organization that provided your initial funds also funds ongoing projects (some funders do not) and you have solid results, find out if they would be open to continuing to support your work. If they do not, reach out to other funders that know you, assuming your program or service fits within those areas they fund. It is well-known among those in the funding game that funders prefer to fund those they know and those that have consistently delivered the goods. The risk to the funder is considerably less if they know where the money is going, how it will be spent, and if the awardee has a good track record of fiscal responsibility and program results. This is equally true whether you are talking about local philanthropic funders or state and national governmental agencies―building a strong relationship with your funder and delivering result is a proven winning formula.
If the organization that provided your seed funding does not fund ongoing operations, or for any other reason it may be difficult to approach your initial funder or other funders that know you, then you must begin your search for another funding entity. While this process can take some time, especially if you are new to the funding game, it is not that difficult to identify organizations with funding opportunities that may be open to hearing about your results and receiving a proposal. There are numerous information services that identify funding opportunities across the country that can be accessed for free (e.g., www.grants.gov for government opportunities, www.ruralhealthinfo.org for rural opportunities) or for a fee through a subscription arrangement (e.g., www.grantwatch.com and www.grantstation.com), to name just a few. These services cover a wide range of funding opportunities from governmental agencies to local, state, regional, and national philanthropic foundations and can serve as a good way to locate organizations that fund the type of work you do. While there are many professional firms that will do this searching for you for a fee, which is often quite steep, with a little time and perseverance you can do the searches yourself.
At the end of the day, achieving financial sustainability for your new CCC is not that difficult so long as you remember to begin to plan for the need early on during your initial start-up period and, most importantly, you generate solid, demonstrable, in-demand results that funders are eager to pay to support.
About the author
Dr. Keith Kosel, Executive Advisor 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.
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By Jacqueline Naeem, MD, PCCI’s Senior Medical Director
By Kimberly Roaten, PhD, CRC, Parkland Health & Hospital System’s Director of Quality for Safety, Education, and Implementation
The month of September is designated as Suicide Prevention and Awareness Month, offering an opportunity to bring awareness and support to mental health organizations and individuals in Dallas who are helping those in need. An initiative led by Parkland Health & Hospital System (PHHS) and Parkland Center for Clinical Innovation (PCCI) reveals important information about suicide risk among Dallas residents.
While national and international efforts to prevent suicide are ongoing, the problem continues to grow. Over the last decade, healthcare systems have seen a rise in the number of individuals with psychiatric needs and suicide risk. As outlined by the American Foundation for Suicide Prevention (AFSP), suicide and suicide attempts continue to plague the healthcare sector:
Many individuals who die by suicide have had contact with a healthcare provider in the weeks and months prior to death, but often this contact is with primary care or emergency medicine providers who may not identify the risk. With the aim of stemming this problem, PHHS implemented a proactive suicide risk identification and prevention program in 2015 which includes screening all patients ages 10 and older for suicide risk regardless of their presenting problems. Approximately 40,000 screenings are completed per month and over 4 million screenings overall. The Universal Suicide Screening Program at PHHS is an example of how meet and exceed The Joint Commission National Patient Safety Goal 15.01.01, targeting suicide risk and has yielded important data about the prevalence of risk in healthcare settings.
Through collaboration with Parkland Clinical Leadership, PCCI has applied data analytics to understand insights from Suicide Screening Program data, which can be used to identify opportunities to improve the current care pathway. Identification of previously undetected suicide risk leads to timely assessment by a health care provider and connection to appropriate services and resources.
Importantly, analysis of data from the program revealed that 2.3% of individuals who have an encounter for a non-psychiatric complaint endorse suicide risk factors (2,735 pediatric patients and 65,000 adults), underscoring the importance of proactive screening and assessment in all patient populations. Patients who are at risk are assessed, provided with brief evidence-based interventions, and then referred for appropriate ongoing care.
Parkland and PCCI are identifying important ways to prevent suicide and self-directed, but everyone can work together to prevent suicide. Knowing the warning signs and how to find help are two important steps in addressing this critical issue. National Suicide Prevention Month is a wonderful way to raise awareness and improve advocacy. If you are someone you know is struggling with suicidal thoughts or suffering and in need of support, there are excellent resources in North Texas including AFSP’s North Texas Chapter. Our collective efforts can help those at risk.
(Are you in Crisis? Call 800-273-8255 or text HOME to 741741.)
By Keith Kosel, Executive Advisor at Parkland Center for Clinical Innovation
We ask this type of question every day. For example, we may ask― “Is this product that I purchased making a difference?” or “Is this advanced training that I completed making a difference?” Implicit in this common question is the expectation that because we have made an investment in something to achieve a result, the result should be better or more improved than the pre-investment state. So too with a Connected Community of Care (CCC). As I have discussed in previous blogs, establishing a CCC requires a substantial investment in both time and money. Therefore, it is only natural to ask― “Is this CCC making a difference, and how would I know?” Unfortunately, most CCCs are established with very little forethought given to this exact question. While we expect the CCC will help community residents improve their health and well-being, how will we know conclusively that this has happened? How will we demonstrate its impact to a potential partner or― more importantly― a funder? This is where data, measurement, and evaluation come into play. For most people, these three words cause anxiety levels to immediately rise. But this doesn’t need to be the case; a little planning and forethought can go a long way to assuaging one’ anxiety when asked the question, “Is your CCC making a difference?”
Before we think about what data we will need to answer this question or how we will collect it, we first need to establish what we mean by “making a difference”. Understand, there is no one correct answer to this question. What may constitute a positive difference or impact for one organization may be much different for another, even similar organization. Many factors contribute to the final answer and each are usually organization-, ecosystem- and situation-specific.
In practice, there are many ways to define making a difference. First, we can look at quantitative or numeric information to make this determination. Are we providing more nutritious meals to indigent residents? Is the number of inappropriate Emergency Department visits declining or, conversely, is the number of residents having visits with a primary care provider increasing? All of these effects can be counted and judged against some predefined goal (more on this later). Second, we can assess making a difference by asking the people that are being touched by the CCC. Through surveys or brief interviews, community residents can tell you in their own words what impact, if any, the CCC has on their lives. While this qualitative (non-numeric) information can often be more informative than simple quantitative information because it represents the voice of the individual, to answer the question of whether your CCC is making a difference, you will also still likely need to establish numeric goals. A third way to assess whether your CCC is making a difference is indirectly via the financial and non-financial opportunities that arise as a result of having a CCC versus not having one. For example, having a CCC may make it much easier to perform contact tracing among vulnerable populations during a pandemic like COVID-19.
Having a CCC may also enable a healthcare system or a community-based organization (CBO) to apply for a grant that it otherwise might not be competitively positioned to do if it did not have an integrated system of healthcare and social service providers such as a CCC.
Regardless of the approach to define making a difference, the importance of planning for 1) what things will be measured to generate the necessary data, 2) how and when that measurement will take place, and 3) how the resulting data will be analyzed and evaluated, cannot be underestimated.
Similarly, these decisions cannot be put off until a later date as is often seen with start-ups, including CCCs. While it is natural to want to focus on the more immediate needs associated with launching a CCC, deferring the question of how we will know if the entity is making a difference can prove costly, both from an operational and financial perspective. At the Parkland Center for Clinical Innovation (PCCI) we encourage those planning a CCC to devote the necessary time early on to setting performance goals and objectives and determining how and when they will be measured and evaluated. While it is important to explicitly build this step into your CCC planning phase, the scope and scale of the work does not have to be extensive. In fact, at PCCI we strongly encourage CCCs to start small with a limited set of goals, objectives, and requisite measures and then scale up as the CCC grows and matures. This approach has the dual benefit of providing essential core information early on while also not overwhelming the CCC staff with data collection activities that may be a distraction from more pressing, day-to-day activities.
Based on this author’s work with literally hundreds of healthcare and social service provider organizations, experience suggests that most entities (both new and established organizations) do best if they initially establish 1) a limited number of goals― one or two at most, 2) a similar number of objectives to achieve each goal, and 3) no more than three to four performance measures to support each goal. While this may seem like an insufficient number of performance elements in today’s data-obsessed world, remember that you can always add additional goals, objectives, and measures as your expertise and comfort levels allow and as your CCC evolves.
Even more important than the numbers, however, it is essential to get the selection of the goals, objectives, and performance measures correct. Each of these three performance elements plays an essential role in helping you answer the question “Is my CCC making a difference?” Your goals focus on the long-term― what do you ultimately want to happen, while your objectives are the short-term accomplishments that help you achieve your goals. In both cases, you must be sure that what you are expecting is both realistic and appropriate for your CCC’s stage of development. For example, assuming a newly established CCC will reduce ED utilization in its first year or two may not be reasonable and may lead to frustration and disillusionment if the goal is not achieved. If you select a BHAG (Big Harry Audacious Goal), you must allow sufficient time (and then some) for all the necessary pieces to come together. The rule of thumb for large-scale demonstration projects such as launching a CCC is that they 1) take (much) longer than expected, 2) cost more than budgeted, and 3) generally initially deliver less than expected. These facts should not dissuade you from your journey, but rather help you keep things in perspective as the project evolves to one that in the long-term is viewed as valuable in achieving your goals.
If getting the goals and objectives correct is important, then selecting the correct performance measures and designing a feasible measurement plan is paramount. Here again, quality is more important than quantity. A few well-chosen performance measures, implemented correctly, will generate far more in the way of actionable data than a plethora of randomly selected measures. To optimize your ability to assess if your CCC is making a difference, your performance measures should be collected at regular intervals following the launch of the CCC. While many established programs collect, analyze, and evaluate performance data on a quarterly basis, for fledgling CCCs, PCCI recommends this data be collected monthly for at least the first one to two years or until the CCC reaches a stable level of operations. While monthly data collection requires a little more work, the more frequent feedback allows you to make necessary program or operational modifications more quickly and with fewer disruptions than that afforded with quarterly feedback. If measurement and evaluation is an area where you don’t have a lot of experience, reach out to others that do, especially individuals and organizations such as PCCI that have experience assessing performance in large-scale, multi-sector collaborative projects.
While we all hope that the answer to the question “Is my CCC making a difference” is yes, the answer may be no early on in the life of a CCC. As disheartening as this news may be, it’s important to not give up, but to look critically at what is working and what is not and make adjustments where necessary. Usually, this examination does not necessitate a complete “reboot” of the CCC initiative, but rather requires making minor changes accompanied by paying closer attention to the CCC’s operations. Seek feedback from your staff and those you serve and be open to change, where change is warranted. As indicated, these types of projects take a lot longer to reach fruition than most people believe, but with a solid plan, patience, and flexibility, you will be able to answer, “Yes, my CCC is definitively making a difference in the lives of the community residents it serves.”
About the author
Dr. Keith Kosel is an Executive Advisor at Parkland Center for Clinical Innovation (PCCI) and is co-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.
Why this post
More than a year ago, the data scientists at Parkland Center for Clinical Innovation (PCCI) committed to take the fight to COVID-19 by assisting North Texas residents, community leaders and public health officials through delivering actionable pandemic intelligence.
Many of us at PCCI and in the community have suffered the loss of family members, colleagues, coworkers, neighbors and friends. So with great relief we have witnessed tremendous scientific achievements in the development, approval and distribution of COVID-19 vaccines within a year. We have also seen the community evolve and adapt to life with COVID-19 and the actions expand from initial testing strategies to vaccine deployment, herd immunity projections and tracking, to now overcoming vaccination hesitancy and surveillance tracking of emerging variants, re-infections and individual/community immunity.
As our community and pandemic efforts evolve, so does the intelligence it needs. To meet that need, PCCI is evolving its technology and is pleased to announce the next phase of the Vulnerability Index.
What is the Vulnerability Index?
The Vulnerability Index is a measure of risk a community faces due to COVID-19. Higher risk means that people may be more likely to be infected with COVID-19, and if they do, they are more likely to experience symptoms and potentially face hospitalization and even death.
When the Vulnerability Index was first built, it covered factors correlated with COVID-19, including attributes in the community that don’t change quickly (like proportion of elderly population, people living with chronic conditions that are associated with COVID-19, and social determinants of health) as well as dynamic factors that increase immediate risk, like active COVID-19 cases and the mobility of the people living in the community.
How has the Vulnerability Index changed?
The North Texas community has evolved in two very important ways, and so the Vulnerability Index is changing as well.
An important caveat is that COVID-19 variants can continue to arise. PCCI is conducting ongoing surveillance on reinfections across Dallas County to assess the emergence of new variants, transmission and potential drop off of previously developed immunity. If this happens it means the mediating effect of the vaccination against COVID-19 risk may be decreased – so more people face infection risk. This is also captured in the updated Vulnerability Index.
How is the Vulnerability Index used?
The Vulnerability Index is used to inform how the communities and municipalities across Dallas County coordinate efforts to improve access to testing, vaccinations and create a path towards herd immunity. Below is a balloon plot, which shows cases on the horizontal axis and vaccinations on the vertical axis. It highlights HI progress in early April for ZIP codes across Dallas County. Each circle represents the current progress; each tail shows the improvement over two weeks. Upward “balloon” trajectory is favorable as it indicates that improvement was a result of vaccinations, not infections.
Source: The Parkland Center for Clinical Innovation
One thing that immediately jumps out is that ZIP codes with higher static vulnerability (or long-term risks in a community that do not change quickly such as age, medical comorbidities and social/economic factors) were slower at vaccine uptake. A potential reason for this is social determinants of health (SDOH) – people who live in these zip codes may be in jobs that are not conducive to have the ability to take time off from work and to travel to vaccine sites to be vaccinated. This information is used by community organizers, public health officials, and health care providers to coordinate efforts and target each community in a way that removes barriers to vaccinations and target information and education via convenient and trusted sources.
Excelsior!
Ongoing vigilance against the virus remains key, and this includes getting vaccinated at your first available opportunity. As we enter the second summer in the pandemic, we at PCCI are committed to monitoring for COVID-19’s continued impact on the community, whether through improving the view into impacted communities, the impact of variants, reinfection risk, and more.
For more information about how PCCI has taken the fight to COVID-19, go to: https://pccinnovation.org/taking-the-fight-to-covid-19/
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As part of May’s Asthma Awareness Month and World Asthma Day (May 4), PCCI is presenting its work, partnering with Parkland and the Parkland Community Health Plan, where its platform supporting pediatric asthma has helped thousands of children, dramatically reduced hospital visits and resulted in millions of dollars in cost savings. Following is an overview of the pediatric asthma programs that PCCI has played a key role in developing.
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By Yolande Pengetnze, MD, MS, FAAP,
Senior Medical Director, Parkland Center for Clinical Innovation
Bringing together advanced data science and clinical expertise to help at-risk populations is a primary mission at PCCI and the results derived from our program to help improve care and outcomes for children with asthma, demonstrate the effectiveness of this approach.
Working closely with leaders from Parkland Community Health Plan’s (PCHP) team, PCCI developed a predictive model to help reduce the incidence and cost of asthma-related emergency department (ED) visits and hospitalizations among Medicaid-insured low-income Dallas children.
PCHP and PCCI launched the Pediatric Asthma Quality Improvement Program in April 2015. The program was driven by the large number of PCHP members with asthma. Asthma is the most common chronic disease of childhood affecting over 6 million children in the US and resulting in over 140,000 hospitalizations every year.
Asthma disproportionately impacts low-income, urban, Medicaid-insured children compared with privately insured children. Asthma, however, also is an ambulatory-care sensitive condition, meaning that appropriate outpatient care and self-care can prevent unnecessary ED visits and hospitalizations, with subsequent substantial direct and indirect costs savings. The opportunity was ripe to really help disadvantaged children with asthma.
How the predictive model works
Beginning in 2014, PCCI developed a logistic regression model to predict asthma emergency department (ED) visits or hospitalizations within the following three months for children with asthma, using clinical, health services utilization and socio-demographic variables from Medicaid claims data. The risk prediction model classifies every patient as Very-High-, High-, Medium-, or Low-risk for asthma ED visits or hospitalizations and the prediction is updated every month, based on new data input.
Compared to published predictive models, PCCI’s model has a very good predictive accuracy (C-statistic 0.84), is derived from a relatively large and diverse population [3] and is well-evaluated [4]. The PCCI asthma model is continuously evaluated and updated every year, to improve its accuracy and enhance actionable insights that guide clinical and community-based interventions. Deep learning methods have been and additional social determinants of health (SDoH) data have been evaluated to enhance model accuracy. Communitywide data sources have been incorporated to improve and fully assess model impact. Using this model, we were able to predict high risk asthma patients. We have integrated the risk-score into the electronic health record (EPIC) at Parkland as a Best Practice Alert (BPA), to drive timely and streamlined point-of-care interventions. We also generate monthly reports sent to frontline providers and Case Management teams and other non-traditional stakeholders. The monthly reports contained just the right amount of information on patients’ risk profile to drive seamless clinical and cross-organizational workflow integrations and tailored population-level interventions.
The interventions are adaptable: the reports are used, at the providers’ discretion, to either augment or streamline existing interventions or initiate targeted interventions, depending on clinical/community settings, resources, and priorities. The ultimate goals are to reduce unnecessary hospital utilization and cost, increase patient adherence to medication and preventive office visits, and improve overall health care experience. Moreover, we use the risk prediction model to directly engage higher risk patients into a text messaging program for patient education and medication reminders.
Finally, we used patient’s risk-stratification to identify providers caring for the highest risk patients and community sources of high-risk children for enhanced support for program participation and community-based interventions.
Dallas County Community Health Needs Assessment (CHNA) Quality Improvement (QI) Initiative
In 2019, Dallas County performed a Community Health Needs Assessment (CHNA) through which pediatric asthma was identified as a driver of high morbidity among children in the county. In 2020, a communitywide quality improvement (QI) program was launched aiming to improve asthma outcomes for all Dallas County children through data-driven interventions and cross-systems care coordination, following the PCCI Asthma Program model. To support this community-wide initiative, we enhanced our asthma risk prediction model with the addition of electronic health records data, which, together with claims and social determinants of health (SDoH) data, predict asthma risk among Dallas County children with asthma.
The new model retains a good prediction ability and provides additional clinical insights not previously available using claims data only. With the addition of electronic health records data, our new asthma model can be used for all children irrespective of insurance status, thus expanding the benefits of our program to more vulnerable children with asthma. The asthma text messaging program also has been expanded to impact all children with asthma, irrespective of insurance status.
Moreover, community-based services providers in the social and Public Health sectors have been engaged to use PCCI asthma risk reports for community-based interventions beyond the traditional health care system. Community-based organizations and the Dallas County Health and Human Services department now use PCCI risk reports to drive community-based interventions such as home visits and outreach in community gatherings. The Dallas independent school district is also being engaged to use the risk reports for school-based interventions.
PCCI’s asthma risk model and reports are driving cross-organizational workflows and communitywide care coordination across North Texas, to improve health, educational, and quality of life outcomes for children with asthma and their families.
Insightful Community Risk Mapping
Over the past two years, we have added data insights capability to the program using local and regional maps to identify geographical areas with high risk patients and support targeted community outreach. Overlaying asthma risk maps with SDoH maps (down to the block group level, see above) has uncovered discrete neighborhoods with asthma-risk and high social needs that might contribute to poor asthma outcomes, including transportation and childcare needs. These opportunity maps are driving community engagement to improve health, education, and wellbeing of children with asthma and their families.
Results
Since inception, PCCI’s pediatric asthma population health framework has not only reduced unnecessary hospital visits and costs, it has improved the healthcare experience for thousands of pediatric patients and their parents. The updated five-year impact report includes:
• Program expanded to support the communitywide Dallas County CHNA Asthma Quality Improvement initiative
• ~93,000 unique children with asthma risk-stratified to-date across both initiatives (PCHP and CHNA Asthma QI)
• Over 22,000 children with asthma risk-stratified every month and ~45,000 every year, with a rapidly increasing impact
• Over ~1800 high-risk children with asthma impacted by the text messaging program
• 21 large and medium community healthcare provider practices actively engaged, including two large Federally Qualified Health Centers (FQHC) and Parkland’s large network of community-oriented primary care clinics (COPC)
• Non-traditional community services providers engaged, including community-based organizations, Dallas County Health and Human Services community health workers, and Dallas ISD, using risk reports for community-, home-, and school-based interventions
• Dallas Fort Worth Hospital Council Foundation engaged as a source of comprehensive communitywide data to support data-driven interventions
• 30 – 40 percent reduction in asthma-related ED visits
• 50 percent reduction in asthma-related inpatient admissions
• 32 – 50 percent increase in providers prescription of asthma controller medications
• 50 percent drop in annual total asthma cost to PCHP
• Approx. $30 million saved as a result of the risk-driven, multi-stakeholder pediatric asthma framework
• Moreover, the text messaging program has yielded an additional 6-fold drop in asthma-related ED visits among participants vs. non-participants
• Over 85% of participants remain in the text messaging program for more than 12 months and >90% feel empowered to care for asthma as a result of the program
Ongoing Program Enhancements
As we continue this program, we are evaluating the role of emerging deep learning models to improve our risk prediction model performance and explanation. Our original logistic regression model served as the baseline benchmark against which deep learning model results would be compared. We, also, are looking into adding block-level social determinants of health to provide additional actionable insights into patients’ asthma risk profile.
Claims data have strengths and insufficiencies worth highlighting. Claims data consist of billing codes that health care providers and facilities submit to payers. claims data follow a consistent format and use a standard set of pre-established codes that describe specific diagnosis, procedures, medications, as well as billed and paid amounts [5]. Additionally, claims data document nearly all interactions a patient has across all the health care systems. They capture broader information for patients and provide access to larger and more diverse patient cohort. Claims data, however, have a time lag of about 30 to 90 days due to the processing time before they are finally added to the database and become available for analysis. We have begun the process of bringing in additional and timely data sources to enhance or supplement claims data, including electronic health records data and communitywide health and social data, which are progressively improving the timeliness, accuracy, and insights of our asthma risk prediction models and risk reports.
Conclusion
In conclusion, patient education, preventive care, and appropriate use of asthma controller medications are the cornerstone of effective asthma care. Accurate risk prediction of asthma ED visits or hospitalizations, timely provider reports, patient education, and communitywide stakeholder engagement drive the prioritization of evidence-based interventions tailored to the highest risk patients, to efficiently reduce asthma-related ED visits/hospitalizations and associated costs, and improve care experience among children with asthma. By bringing together all the factors from PCCI’s predictive model and applying them to thoughtful and direct interventions, at-risk group of children and their families can experience better outcomes that are beneficial from the health, cost, societal, and consumer experience perspectives. Through our comprehensive approach to whole-person care, , the benefits of PCCI’s risk -driven asthma quality improvement initiatives, which started with one health plan, are now reaching deeper into the North Texas community, bringing quality, coordinated care to vulnerable children where they live, learn, and play.
About the author
Yolande Pengetnze, MD, MS, FAAP, Senior Medical Director, joined PCCI in December 2013 as a Physician Scientist while remaining a Clinical Faculty at the University of Texas South Western (UTSW) School of Medicine and a practicing pediatrician at Children’s Health in Dallas, Texas. Her interests include the use of advanced predictive analytics integrating traditional and novel data sources to improve health outcomes at the individual and population level. She currently leads multiple projects at PCCI, including two population health quality improvement projects in pediatric asthma and preterm birth risk prevention. She received her MD in 1998 from the University of Yaounde in Cameroon, completed a Pediatric Residency training in 2008 at Maimonides Medical Center in New York City, and a Master of Science in Clinical Science at UTSW.
[1] M. Xu, K. G. Tantisira, A. Wu, A. A. Litonjua, J.-h. Chu, B. E. Himes, A. Damask, and S. T. Weiss. Genome wide association study to predict severe asthma exacerbations in children using random forests classifiers. BMC medical genetics, 12(1):90, 2011.
[2] E. Forno, A. Fuhlbrigge, M. E. Soto-Quirós, L. Avila, B. A. Raby, J. Brehm, J. M. Sylvia, S. T. Weiss, and J. C. Celedón. Risk factors and predictive clinical scores for asthma exacerbations in childhood. Chest, 138(5):1156– 1165, 2010.
[3] M. Schatz, E. F. Cook, A. Joshua, and D. Petitti. Risk factors for asthma hospitalizations in a managed care organization: development of a clinical prediction rule. The American journal of managed care, 9(8):538–547, 2003.
[4] A. L. Andrews, A. N. Simpson, W. T. Basco Jr, R. J. Teufel, et al. Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma. Medicare & Medicaid research review, 3(4), 2013.
[5] W. J and B. A. The benefit of using both claims data and electronic medical record data in health care analysis. Technical report, Optum Insight, 2012.
Update on Dallas County Reaching COVID Herd Immunity From PCCI CEO Steve Miff
In February, Parkland Center for Clinical Innovation (PCCI) forecast that Dallas County had an opportunity to reach COVID herd immunity by mid-June. However, due to slowing vaccination rate, we have updated our forecast of Dallas County reaching the COVID herd immunity threshold to late-June with the possibility of falling back even further into July.
PCCI’s herd immunity forecasts in February was based on 80 percent of the county’s residents either having recovered from COVID-19 or having received vaccinations.
Today, herd immunity for the county is at 64 percent. While is represents progress, vaccination rates have slowed which is having a negative effect on our herd immunity forecast. The key driver making vaccine rates to regress include vaccine hesitancy and uptake, particularly in the working population.
While we’ve made great progress and to date vaccinated over 35% of the Dallas County population, including more than 73 percent of residents over 65 years old, the vaccination rates have been dropping, despite ample supply of vaccines and no wait times. In recent weeks, we’ve been averaging 45,000 vaccines administer per week, down from the mid and upper 60,000s in March. Therefore, due to the reductions in vaccinations, the herd immunity projections have been pushed to late June and could slip even further into July.
The longer it takes us to contain and crush COVID, the more chances the virus has to create new mutations that could be more transmissible, more deadly and more elusive to previously developed antibodies.
We encourage everyone to receive their COVID vaccination sooner than later. The quicker we can reach herd immunity the sooner we can return to safely interacting with our friends and families, teachers return to classes without fear and reduce the strain on our first responders, hospitals and their staff. But most importantly, reaching herd immunity via vaccines will help spare families the hardships of loved ones becoming ill or even losing their lives.
Steve Miff, PhD.
President & CEO
Parkland Center for Clinical Innovation
