DALLAS – In the month following the Thanksgiving Holiday, PCCI’s COVID-19 Vulnerability Index (VI) has recorded values smashing the highest levels ever recorded for Dallas County. Specifically, ZIP codes 75211, 75243, and 75228 posted vulnerability index ratings of 157.96, 121.14 and 104.75, respectively, shattering the highest value of 100 previously recorded in July, which set the VI value benchmark.

PCCI’s Vulnerability Index indicates that the increases are driven by high mobility levels (people leaving their homes) during Thanksgiving and an increase in confirmed cases. PCCI

experts warn that if mobility during the Christmas and New Year’s holidays continues to be high, COVID-19 infection growth could continue at a hazardous rate.

“COVID-19 has been a challenge and, for many, a personal tragedy. The jump over the past month for many ZIP codes above the prior July peak underscores the risk it presents as many celebrate the holidays. The key to keep in mind over the next few months is to maintain patience and diligence as the community begins vaccinations – continue social distancing, wearing masks, diligent hand washing, and other recommendations of public health authorities,” said Thomas Roderick, PhD, Senior Director of Data and Applied Sciences at PCCI.

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

The Vulnerability Index reports that in December, the ZIP code with the highest vulnerability value continued to be 75211, around Cockrell Hill. This area has been a high-risk area since the launch of PCCI’s Vulnerability Index ranking shot up 62.7 points from November to December.

The ZIP code 75243, East of U.S. Highway 75 and intersected by Interstate 635, has experienced a huge increase in its VI value, soaring 85.7 points, going from 35.4 in November to 121.14 in December, making this area the number two most at-risk ZIP code in Dallas County.  Another ZIP Code breaking its VI benchmark from July was 75228. This area, in East Dallas bordered by Interstates 30 and 635 and intersected by Highway 12, saw its VI value grow from 74.33 in November to 104.75 in December, making it the third most at-risk region in Dallas County.

Also, ZIP Codes 75216 and 75150 also saw their VI value grow over 50 points, raising their values to 97.96 and 99.00 respectively.

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

Data Sources:

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

About Parkland Center for Clinical Innovation

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

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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 services.

This section is from Chapter 2, “The Readiness Assessment.” This is a critical step in building connected communities of care as the readiness assessment uncovers the clinical and social needs in the community along with provider and Community-Based Social Service Organizations (aka Community-Based Organizations ((CBOs))) readiness to support care coordination activities that will address the needs of all stakeholders. A readiness assessment utilizes quantitative and qualitative data to provide both the breadth and depth of the required understanding to design and implement a CCC.

PCCI and its partner Healthbox, offers readiness assessments as a service. If you and your organization are interested, go here for more information: https://pcci1.wpengine.com/connected-communities-of-care/.

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HOW PCCI USED ITS READINESS ASSESSMENT TOOL TO LAY THE GROUNDWORK FOR THE DALLAS IEP

In 2012, shortly after receiving funding from the Communities Foundation of Texas, PCCI developed its PCCI Readiness Assessment and began the process of identifying clinical, social, and technological needs in the Dallas market, along with a list of potential Partner and Participant organizations to form the initial IEP. The following describes some of the key PCCI findings across the five requirements resulting from that exercise.

Target Clinical/Behavioral Health Conditions
PCCI’s Readiness Assessment recommended an initial target of up to 10 clinical/behavioral health conditions. The Clinical Advisory Group then pared that number down to three or four clinical/behavioral health conditions based on an analysis of the following:

• Prevalence rates of chronic diseases at Parkland and in the Dallas community at large
• Desired alignment with nationwide Health Information Exchange (HIE) efforts
• Data from surveys and semi-structured interviews with local clinical and CBO leaders
• Interventions that were available and deemed to be effective

Based on these factors, the Dallas Clinical Advisory Group unanimously decided that diabetes, Congestive Heart Failure (CHF), and Hypertension (HTN) would be the initial, prioritized conditions. In addition, the Clinical Advisory Group determined that behavioral health, pediatric asthma, and Chronic Obstructive Pulmonary Disease (COPD) should be targeted in later implementation phases.

Target Social Needs that Impact Clinical Outcomes
Within the Parkland community, the Stemmons Corridor, South Dallas, Southwest Dallas, and Southeast Dallas were all home to populations with the highest medical needs. These same areas had high incidences of the three targeted, chronic health conditions identified in the first readiness assessment requirement. These same areas also had a high proportion of adults with less than a high school diploma and the highest levels of poverty in Dallas. The areas of Southwest Dallas, Southeast Dallas, and South Dallas had correspondingly low per-capita incomes and high unemployment. Additionally, large numbers of households in all four areas were on the Supplemental Nutrition Assistance Program (SNAP/food stamps). Based on the in-depth interviews with clinical and CBO leaders, the top five unmet social needs are described in Table 2.1.

Population That Would Be Targeted by the IEP
Parkland’s outpatient population is disproportionately indigent and vulnerable. The population characteristics of interest included (1) demographics, (2) insurance, (3) clinical conditions, (4) barriers to healthcare, (5) unmet medical needs, (6) unmet social needs, (7) Parkland service utilization patterns, and (8) possible information-sharing concerns.

To gather the necessary information, PCCI conducted surveys with clients at CBOs and with patients at Parkland clinics. The survey data showed the following:

• Clinical Conditions. HTN and diabetes were among the top chronic medical conditions reported by clients/patients.
• Demographics. Client/patient educations levels were low, and most surveyed clients and outpatients fell below the federal poverty level.
• Insurance. Most clients/patients had either Parkland Community Health Plan insurance or no insurance.
• Healthcare Barriers. The top three barriers to healthcare were (1) the inability to pay for care, (2) transportation problems, and (3) lack of health insurance.
• Unmet Health Needs. The top three unmet health needs were (1) dental care, (2) vision care, and (3)  transportation for healthcare services.
• Unmet Social Needs. The top three unmet social needs were (1) transportation, (2) financial assistance for rent or utilities, and (3) assistance in applying for insurance.
• Information Sharing. Survey results indicated that nearly 90% of patients were comfortable sharing information about themselves and their care with healthcare providers and CBOs participating in the Dallas IEP.

Organizations and Potential Users of the CCC Model
By profiling the CBOs active in the Parkland area, the PCCI Readiness Assessment aimed to define the functional requirements, user-training needs, and governance model that would achieve optimal alignment. An understanding of the organizational settings also aided in developing a strong value proposition benefiting each CBO and their service populations. Based on the survey data, the CBOs were diverse and varied by size, services provided, technical capacity, and client populations served. There was also a wide range of potential users within organizations, including volunteers, case workers, community health workers, and directors. As a result, users had different education and training backgrounds, often with limited prior experience using—and interpreting—health information. The majority of CBOs provided case management, daily living skills training, job-seeking assistance, and substance abuse counseling. Most CBOs wished to exchange medical and social Information to better serve their clients. Information deemed especially valuable included (1) scheduled appointments, (2) medication lists, (3) inpatient discharge instructions, and (4) insurance eligibility.

Develop Use Cases for the IEP
The development of a library of use cases illuminated how the use of an IEP could potentially result in a better clinical or social outcome for the patient. In addition to the series of interviews with leaders at Parkland and CBOs covering a range of different program types and client populations, PCCI also conducted “deep-dive” focus groups with leadership and frontline staff from 15 CBOs (52 attendees). These meetings fostered a rich exchange on at least 20 different scenarios in which an IEP could potentially be used, as well as barriers and enablers to using the platform. Most CBOs wanted the ability to track clients, identify services for which their clients qualified, and view (1) past and current referrals and resources provided, (2) demographic information, (3) relevant medical history, (4) standard documentation required by Parkland or social service agencies, and (5) client/patient insurance coverage.

The discussions with community and clinical leaders generating the list of “uses” resulted in five CCC use-case categories: (1) background information (e.g., demographic information, insurance coverage); (2) service eligibility (e.g., service eligibility identification); (3) service history (e.g., relevant medical history, current medications, past service enrollments); (4) service planning, coordination, and delivery (e.g., service request/referral at other agencies, client encounters at other agencies, medical equipment, or dietary needs); and (5) research and reporting (e.g., research study participation). Each use case incorporated the interactions between healthcare providers and CBOs and addressed one or more requested functional requirement.

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Please contact PCCI today, if you are interested in a readiness assessment at: https://pcci1.wpengine.com/contact/.

Also, you can register your team for our Executive Book Club where you can and receive a complimentary set of “Building Connected Communities of Care” books with a consultation from one of our experts, go to: https://pcci1.wpengine.com/playbook/.

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

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

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

Connecting these various entities and forming a two-way communication pathway is an electronic information exchange platform termed Pieces™ Connect, which allows for real-time, two-way sharing of information pertaining to an individual’s social and healthcare needs, history, and preferences. The information exchange platform is the glue that holds the physical network together and provides one of the mechanisms to disseminate information from public health and healthcare entities to social service providers in the community. It allows the individual community resident, via the CBO, to become better informed about important health issues, such as routine vaccinations or preventive care, such as social distancing and proper mask usage during a pandemic.

Until recently, the primary mission of the Dallas CCC focused on addressing residents’ social determinants of health (SDOH) issues through providing community resources (e.g., food assistance, housing, transportation) to improve the lives of Dallas County residents. While this mission has become even more critical during the COVID-19 pandemic, the work of the Dallas CCC has also evolved to include identifying COVID-19 sites within the County and directing community outreach efforts to help stem the rapid spread of the virus.

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

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

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

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

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

About the author

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

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

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

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

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

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

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

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

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

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

 

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

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

 

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

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

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

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

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

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

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

Data Sources:

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

About Parkland Center for Clinical Innovation

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

 

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

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

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

PCCI data science and clinical experts, along with team leaders at Parkland Health and Hospital System,  have published a new paper about the Parkland Trauma Index of Mortality* on arXiv®. arVix is an open archive for scholarly articles maintained and operated by Cornell University. The paper “Parkland Trauma Index of Mortality (PTIM): Real-time Predictive Model for PolyTrauma Patients” explores how a machine learning algorithm that uses electronic medical record data to predict 48−hour mortality during the first 72 hours of hospitalization.

“This project is an outstanding collaboration between PCCI and Parkland and probably first of its kind dynamic and real-time predictive model for polytrauma patients,” said Manjula Julka, MD, MBA, Vice President, Clinical Innovation at PCCI. “Dr. Adam Starr, distinguished ortho trauma surgeon at Parkland, is a key leader in this project. Parkland’s trauma center is committed to providing state-of-the-art innovative, high quality care for best health outcomes. This paper outlines how we were able to leverage machine learning to help predict mortality for trauma patients in a way where surgery and critical care teams are able to use this, along with other clinical decision support tools, as a way to help save lives.”

To view and download the paper, click on the image below:

 

*The Parkland Trauma Index of Mortality model is a free software and is distributed under the terms of the GNU Lesser General Public License (LGPL).

By Keith C. Kosel, PhD, MHSA, MBA

Parkland Center for Clinical Innovation

 This question initially brings to mind many possibilities such as connection to the latest 5G cellular service, a new super-fast internet provider, or maybe one of the many new energy suppliers jockeying for market share from traditional utility companies. While all of these might represent legitimate opportunities to improve one’s community, here we are talking about a different concept; specifically, whether your community is ready to have a Connected Community of Care (CCC) to advance whole person health.

The image of a CCC may seem obvious. After all, we all live in communities where we have some connections between hospitals, physician practices, ambulatory care centers, and pharmacies to name just a few. But here we are talking about a broader sense of connected community that includes not just health care organizations, but social service organizations, such as schools and civic organizations and community-based organizations (CBOs) like neighborhood food pantries and temporary housing facilities. A true CCC links together local healthcare providers along with a wide array of CBOs, faith-based organizations and civic entities to help address those social factors, such as education, income security, food access, and behavioral support networks, which can influence a population’s risk for illness or disease. Addressing these factors in connection with traditional medical care can reduce disease risk and advance whole person care. Such is the case in Dallas Texas, where the Dallas CCC information exchange platform has been operating since 2012. Designed to electronically bring together local healthcare systems, clinicians, and ancillary providers with over a hundred CBOs, the Dallas CCC provides a real-time referral and communication platform with a sophisticated care management system designed and built by the Parkland Center for Clinical Innovation (PCCI) and Pieces Technologies, Inc.

Long before this information exchange platform was implemented, the framers of the Dallas CCC came together to consider whether Dallas needed such a network and whether the potential partners in the community were truly ready to make the commitments needed to bring this idea to fruition. As more and more communities and healthcare provider entities realize the tremendous potential of addressing the social determinants of health by bringing together healthcare entities and CBOs and other social-service organizations, the question of community readiness for a CCC is being asked much more often. But how do you know what the right answer is?

Before looking at the details of how we might answer this, let’s remember that a CCC doesn’t don’t just happen in a vacuum. It requires belief, vision, commitment― and above all― alignment among the key stakeholders. Every CCC that has formed, including the Dallas CCC, begins with a vision for a healthier community and its citizens. This vision is typically shared by two or more large and influential key community stakeholders, such as a   large healthcare system, school district, civic entity, or social- service organization like the United Way or Salvation Army. Leaders from these organizations often initially connect at informal social gatherings and advance the idea of what if? These informal exchanges soon lead to a more formal meeting where the topic is more fully discussed and each of the participants articulates their vision for a healthier community and what that might look like going forward. This stage in the evolution of a CCC is perhaps the key step in the transformation process, as while all stakeholders will have a vision, achieving alignment among those visions is no small feat. Many hopeful CCCs never pass this stage, as the stakeholders cannot come to agreement on a common vision that each can support. For the fortunate few, intrinsic organizational differences can be successfully set aside to allow the CCC to move forward.

It’s at this point in the CCC’s evolution that details begin to matter in truthfully answering the question, “Is this community ready to be connected?” While there may be agreement among the key stakeholders on a vision, the details around readiness may still divert or delay the best-laid plans. It is safe to say that the key to understanding a community’s readiness to form a CCC lies in the completion of a formal, comprehensive, and transparent readiness assessment. A readiness assessment is a process to collect, analyze, and evaluate critical information gathered from the community to help identify actual clinical and socio-economic needs, current capabilities and resources (including technology), and community interest and engagement. Taken together, a comprehensive readiness assessment can help identify a community’s strengths and weaknesses in preparation for establishing a CCC. A readiness assessment is not a tactical plan for building a CCC, nor is it a governance document that provides how all members of the CCC will relate to each other. Instead, the readiness assessment provides communities interested in establishing a CCC with an honest and unbiased yardstick to measure preparedness. Conducting and using the results of the readiness assessment is one of the best ways to ensure a successful CCC deployment.

A typical CCC readiness assessment covers five areas: (1) community demographics; (2) clinical areas of need (including trends); (3) social areas of need (including trends); (4) technology competency (e.g., what percent of the potential network participants are computer literate?), availability (e.g., what percent of the potential network participants have internet access?), and suitability (e.g., is the internet access, high speed?); and (5) what are the needs of potential network participants and can these be modeled as use cases for the information exchange network? This information is essential to help key stakeholder decision-makers decide to move forward with establishing a CCC and to know what specific challenges may lie ahead.

The collection of this essential information can be done in a number of ways, such as making use of existing publicly reported data or conducting surveys, interviews, focus groups and townhall meetings with community leaders and residents and clinical and CBO leaders and staff. Experience conducting the readiness assessment that provided the foundation for the Dallas CCC showed that no single information-collection method was sufficient to collect the necessary level and robustness of the data. In Dallas, we utilized all five approaches but found that in addition to researching publicly available data, initial surveys, followed by interviews and focus groups, yielded the most voluminous and reliable information to chart the course ahead.

In addition to the various methods to collect this essential information, the key to obtaining useful and reliable information requires a sufficient number of respondents/participants who are drawn from various organizations and organizational levels. Simply put, you must have a large enough sample and you must have diversity within the sample. It’s not enough to just interview leaders of potential network participants, as their understanding of the needs, trends, and capabilities may look very different from that of frontline staff. Similarly, surveying only one category of potential network participants may not provide enough information to  fully understand the socio-economic needs in the community or even the perspectives surrounding the prevalence of chronic conditions. Beyond the qualitative methods involved, it is important to note that if done right, this process takes a lot of time to complete. Cutting corners by reducing the sample size, for example, or doing selective sampling to speed the readiness assessment process along will only cause problems later when this insufficient information results in erroneous decision-making.

Once the data has been collected, it is important to carefully analyze what the data is trying to tell you. Results of the readiness assessment must be shared openly and honestly with all key stakeholders, particularly those serving in a governance capacity. The governance group (a topic for another day) that has formed in parallel with the readiness assessment must be able to evaluate and understand the main messages from the readiness assessment to make an informed decision as to whether to move forward with establishing a CCC. Like the need for alignment around the key stakeholder’s vision for the CCC, there must be universal agreement by the key stakeholders as to the message of the readiness assessment and its implications for the road ahead. As with the vision alignment stage, substantive disagreements among the group at this stage are a sign of trouble ahead unless differences can be resolved.

At this point you might be thinking that this all seems very complicated and fraught with potential land mines waiting to derail your effort to answer the original question “Is your community ready to be connected?” Again, I would emphasize the importance of unwavering commitment and alignment to achieve the vision. But I would also offer advice gleaned from working in the CCC space for the last eight years, which is to get help early and don’t wait until the horse is out of the barn! We have seen first-hand many communities and consultants approach the conduct of a readiness assessment with a cavalier attitude, often exemplified by the statement, “we already know all of this,” only later to have to backtrack their pronouncements at substantial additional cost in time and resources. Fortunately, today there are a number of excellent organizations, including PCCI, with the experience, credibility, and integrity in the CCC space to help you on this journey. Don’t be afraid to seek them out. It will be a wise investment that you will not regret, particularly when you begin to see the results of improved whole person health and well-being in your community.

About the author

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

 

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By Manjula Julka, MD, MBA, PCCI’s Vice President, Clinical Innovation

By Albert Karam, MS, PCCI’s Director of Data Governance and Analytics

Since the earliest days of the COVID-19 pandemic, one of the biggest challenges for health systems has been to gain an understanding of the community spread of this virus and to determine how likely is it that a person walking through the doors of a facility is at a higher risk of being COVID-19 positive.

Without adequate access to testing data, health systems early-on were often forced to rely on individuals to answer questions such as whether they had traveled to certain high-risk regions. Even that unreliable method of assessing risk started becoming meaningless as local community spread took hold.

Parkland Health & Hospital System (the safety net health system for Dallas County, TX) and PCCI (a Dallas, TX based non-profit with expertise in the practical applications of advanced data science and social determinants of health) had a better idea. Community spread of an infectious disease is made possible through physical proximity and density of active carriers and non-infected individuals. Thus, to understand the risk of an individual contracting the disease (exposure risk), it was necessary to assess their proximity to confirmed COVID-19 cases based on their address and population density of those locations. If an “exposure risk” index could be created, then Parkland could use it to minimize exposure for their patients and health workers and provide targeted educational outreach in highly vulnerable zip codes.

PCCI’s data science and clinical team worked diligently in collaboration with the Parkland Informatics team to develop an innovative machine learning driven predictive model called Proximity Index. Proximity Index predicts for an individual’s COVID-19 exposure risk, based on their proximity to test positive cases and the population density. This model was put into action at Parkland through PCCI’s cloud-based advanced analytics and machine learning platform called Isthmus. PCCI’s machine learning engineering team generated geospatial analysis for the model and, with support from the Parkland IT team, integrated it with their Electronic Health Record system.

Since April 22, Parkland’s population health team has utilized the Proximity Index for four key system-wide initiatives to triage more than 100,000 patient encounters and to assess needs, proactively:

1. Patients most at risk, with appointments in 1-2 days, were screened ahead of their visit to prevent spread within hospital
2. Patients identified as vulnerable, were offered additional medical (i.e. virtual visit, medication refill assistance) and social support
3. Communities, by zip-code, most at-risk were sent targeted messaging and focused outreach on COVID-19 prevention, staying safe, monitoring for symptoms, and resources for where to get tested and medical help.
4. High exposure risk patients who had an appointment at one of Parkland’s community clinics in the next couple of days were offered a telehealth appointment instead of a physical appointment if that was appropriate based on the type of appointment.

5. Proximity Index to other organizations in the community – schools, employers etc., as well as to individuals to provide them with a data driven tool to help in decision making around reopening the economy and society in a safe, thoughtful manner.

Figure 1 PCCI’s Proximity Index Process

In the future, PCCI is planning on offering

Many teams across the Parkland family collaborated on this project, including the IT team led by Brett Moran, MD, Senior Vice President, Associate Chief Medical Officer and Chief Medical Information Officer at Parkland Health and Hospital System.

About the Authors

Manjula Julka, MD, FAAFP, MBA, is the Vice President of Clinical Innovation at PCCI. She brings more than 15 years of experience in healthcare delivery transformation, leading a strong and consistent track record of enabling meaningful outcomes.

Albert Karam is a data scientist at PCCI with experience building predictive models in healthcare. While working at PCCI, Albert has researched, identified, managed, modeled, and deployed predictive models for Parkland Hospital and the Parkland Community Health Plan. He is diverse in understanding modelling workflows and implementation of real time models.

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