Blog Archives – PCCI

22 June 2020

PCCI’s Vulnerability Index: Taking the fight to COVID-19

Read our blog about how PCCI’s team of clinical and data science experts developed the PCCI Vulnerability Index as a way to assist community and healthcare leaders to address the factors that cause COVID-19’s exponential spread. Click on the image below to view the blog:


11 March 2020

Book Excerpt: ‘Building Connected Communities of Care’ Six Tracks Needed for a Connected Community

In a new book, “Building Connected Communities of Care,” published by PCCI, the authors Keith Kosel, PhD, and Steve Miff, PhD, created a playbook that offers a step-by-step program for coordinating medical and community-based resources to change how, where and when healthcare is delivered.

The book is a practical, how-to guide for health systems, payers, communities, philanthropic agencies, foundations, and policymakers desiring to streamline coordination and assistance efforts between medical and social services to reduce costs and improve the health, safety, and well-being of a community’s most vulnerable residents, especially those with chronic diseases and complex social needs.

The book is informed by PCCI’s experience building one of the first Connected Communities of Care in the nation, which was not an overnight proposition. The PCCI experience in Dallas highlighted that dedicated time, clear process, allocated resources and extreme collaboration were all needed  to align diverse and essential stakeholder groups. The playbook organizes activities needed  to build a Connected Community of Care into six specific tracks – all of which must be addressed, and all of which are vital for lasting success.  Following is an excerpt from the book:

Chapter 1, page 3:

The Six Tracks for CCC Implementation  

The figure (left) illustrates the six tracks of activity needed to create a Connected Community of Care (CCC). Development activities begin in the center to develop governance models, procedures and legal policies that reflect the values of the key stakeholders and the specific goals of the CCC.   Each additional Track has defined activities – activities within a Track build as a program moves from planning, to initial launch, to on-going sustainability;


PCCI’s Connected Communities of Care Model 


While PCCI recommends that CCC leaders pursue the Tracks in the following general order, much of the work in various Tracks can (and should) be performed in parallel with work in other Tracks.

PCCI recommends that the CCC leaders assign a designated Track lead for each specific Track. The work in the six CCC Tracks will also require input from additional stakeholders specific to the implementation of that particular Track. The six Playbook Tracks are:

  1. Governance Track. A CCC’s governance structure relies on a collective decision-making model rather than on leadership by a specific individual or organization. This Playbook assumes that a few key community organizations have already formed an initial steering group to make the significant decision to undertake the CCC initiative. It is critical, at least initially, for an empowered, established group of decision-makers to provide leadership through a “readiness assessment” process and during the initial CCC design stages. The “readiness assessment” comprises a set of activities designed to collectively uncover a community’s clinical and social needs and level of preparedness and commitment to hosting a CCC.
  2. Legal/Policy Track. Communities should identify considerations related to contracts, policies, and procedures to provide an overall CCC legal and policy framework for Governance and as part of the development of each Track. The construct of a legal framework requires a review of applicable federal, state, and local law, along with requirements imposed by Funders, Sponsors, and clinical and community Partners. As these requirements and considerations are tightly integrated with the business requirements, PCCI has incorporated some of the Legal/Policy considerations within each respective Track. The CCC’s Legal /Policy Track lead and CCC legal counsel should review all relevant key documents in all Tracks to ensure compliance. To streamline CCC preparation and implementation, PCCI recommends that CCC legal counsel leverage Participants’ existing legal structures, policies, processes, and agreements, where possible.
  3. Technology Platform Track. The Governance Track provides a framework for strategic assessment of CCC technology needs, ranging from required features to market analysis. The Technology Platform Track builds off that strategy and explores in depth the nuances and critical activities necessary to ensure successful deployment of the CCC’s backbone – the data-sharing platform. The technology infrastructure creates an integrated electronic platform to exchange clinical and social information securely between health organizations (i.e., hospitals, clinics) and CBOs (e.g., homeless shelters, food pantries) that are part of the CCC network. Construction of the platform should facilitate future data and external solution integration and provide an information exchange platform on which to customize additional case-management functionalities to meet the CCC users’ service-coordination requirements.
  4. Clinical Providers Track. Although clinical CCC workflows vary across selected clinical sites, the workflows need to converge on the CCC’s common goals. The Clinical Provider Track lead should contemplate the key factors and related nuances in establishing the clinical CCC consortium, including but not limited to the following: executive sponsorship; clear definition of roles and responsibilities; handling of clinical information; the compliance framework; and integration of the new workflows resulting from this work.
  5. Community Partners Track. Community workflows also require consideration of a unique set of circumstances, relationships, and nuances. Even more so than the clinical-provider workflows, community workflows vary widely across CBOs, but ultimately must align to support the global CCC goals. Leadership, staffing, and management models may vary from those of the clinical Partners, thus requiring dedicated, deep expertise from the Community Partners Track lead working to engage CBO Partners.
  6. Program Sustainability Track. Stakeholder and Participant support and revenue generation are two of the most important factors contributing to CCC sustainability. The CCC can garner that support through defining and demonstrating its value in providing better services and outcomes and in creating a vehicle for research and innovation benefiting the entire community. Significant funding may be required to design, build, implement, and sustain your local CCC. Unlike hospital quality-improvement programs that are expected to be deployed and to generate results within annual budgets, CCC deployments require several years to reach scale and maturity in order to produce meaningful Return on Investment (ROI) and Social Return on Investment (SROI) results.

For more information about “Building Connected Communities of Care,” or to get your copy today , go to HIMSS Publishing or

About the authors

Dr. Keith Kosel is a Vice President, Enterprise Relations at PCCI.

Dr. Steve Miff is the President and CEO of PCCI.


12 February 2020

PCCI’s Expert Leadership Leveraging Social Determinants of Health

PCCI is a leader in researching, understanding and implementing social determinants of health (SDOH) programs that have taken a theory into practice, helping save lives, improving care and reducing costs. PCCI leverages data science and social determinants of health to better support under-served populations across our communities, and shows how this is possible with a number of successful programs. 

These are outlined in a groundbreaking series of blog posts showing how SDOH can go from a simple buzzword to a way to help change the way healthcare is delivered.

Please click on the links below to see PCCI’s expert perspectives on SDOH:


By Vikas Chowdhry, MS, MBA, is PCCI’s Chief Analytics and Information Officer


By Manjula Julka, MD, PCCI’s VP, Clinical Innovation


By Leslie Wainwright, PhD, PCCI’s Chief Funding and Innovation Officer


By Steve Miff, PhD, CEO of PCCI


By Steve Miff, PhD, CEO of PCCI


5 February 2020

The Future of SDoH: The Power of Personal Determinants of Health

It is encouraging to see many healthcare systems and payers focusing on the impact of social determinants of health (SDoH) and looking for ways to partner with community-based organizations to address and improve these issues locally. Although this is a necessary step, I believe that providing access or referrals to community organizations is not the full answer. While healthcare systems can provide referrals and connect patients to resources such as food banks or employment resources, it may not be enough to create individual engagement and empowerment to use those resources. We more fully need to appreciate the role played by the environment in which we grow up and the choices available to us in shaping how we respond to SDoH factors as individuals.

As part of an innovation center where we align data science with SDoH to help systematically disadvantaged individuals, I’ve been witness to projects and research that point to the theory of individual resiliency as part of the equation. The American Psychological Association defines individual-level resilience as the process of adapting well in the face of adversity, trauma, tragedy or threats.[1] A review of the research on

resilience by the WHO found that an individual’s ability to successfully cope in the face of significant adversity develops and changes over time, and that interventions to strengthen resilience are more effective when supported by environments that promote and protect population health and well-being. Further, supportive environments are essential for people to increase control over the determinants of their health.[2]

Also, in addition to traditional resilience methods, the emergence of methods to assess an individual’s capacity for self-care are adding significant insights into personal determinants of health. In particular, the needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care. Clinical teams need to acknowledge, respect and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Further, clinical teams need to ensure that social and community workers and public health policy advocates are part of the proposed solution. Researchers at the Mayo Knowledge and Evaluation Research (KER) Unit and the Minimally Disruptive Medicine (MDM) program led by Dr. Kasey Boehmer are developing qualitative methods and measures of capacity and individual’s ability for self-care.

Take post-traumatic stress disorder (PTSD), as an example. It has been estimated that around 50-60 percent of people in the US will experience severe trauma at some time in their lives. Around one in 10 goes on to develop PTSD, which is permanent in a third of cases. But some people who have lived through major traumatic events display an astonishing capacity to recover.[3] A complex set of factors can be attributed increasing an individual’s resiliency to trauma including their personality, their individual biology, childhood experiences and parental responses, their economic and social environment as shaped by public policy, and support from family and friends.

I could apply this to patient engagement as well. In any given population we may be able to determine which factors cause one individual to not only take a referral to a food bank but continue to receive services to improve their food insecurity versus another individual from the same neighborhood and population who did not. Perhaps the first individual connected with a case manager at the food bank who did regular check ins. Maybe they had family or friends who drove them to the food bank weekly or attended nutrition classes at the center that provided them with regular group support.

What might social determinants of health look like in 2025 if we could capture, analyze and use these “resiliency” factors or personal determinants of health? In 2025, SDoH will evolve to:

    • SDoH will evolve and morph intoPDoH – Personal Determinants of Health
    • Policy makers at local, state and federal levels will recognize the role that these factors play toward health and well-being of people and will enact policies to provide support for prevention versus late stage clinical intervention
    • PDoH will be broadly integrated into Cognitive Health Records and built into AI-based risk predictive models
    • Bridging isolation (mental and physical) will be a key focus: Transportation-driven access challenges will be addressed through co-location of services and broadly through digital technology, tele-consults (at non-traditional location such as food pantries) and drone deliveries (everyone loves drones)
    • PDoH will evolve to integrate pharmacogenetic/genetic based data and measures of self-care capacity
    • From my perspective, we will be better at understanding “who are our patients” beyond clinical diagnoses through both AI driven deep neural network analyses of PDoH data and qualitative studies leveraging discrete choice methodologies and other consumer choice and segmentation research methods


In a collaboration between Parkland Health & Hospital System and North Texas food pantries, the partners wanted to test their ability through connected data share and cross-organizational care coordination using a social-to-health Dallas Information Exchange Portal (IEP) to impact the health care experience of food-insecure individuals with diabetes and/or hypertension.

Individuals who sought services at one of the food bank locations and reported to have diabetes/hypertension and seeking care at Parkland were flagged for participation in the program, through coordination with Parkland. At their next visit to the food pantry, they received prescription and appointment reminders, access to healthy food options conducive to their medical condition and any barriers they had to care were identified and recorded in the IEP system.  Parkland providers can see and use the information to proactively address any barriers to care (e.g., prescription refill assistance or transportation assistance to next appointment).

Individuals who were enrolled in the program had a significantly higher outpatient appointment attendance and a near significant decrease in no-show/same day cancellation of appointments versus a control group. In addition, satisfaction surveys showed that 93% of respondents either agree or strongly agree that the program has made them more likely to go to their doctor’s visit. These results seem to strengthen the idea that those individuals with adequate social supports, and connectedness between the health system and community providers increases individual engagement in health and well-being.

About Vikas Chowdhry

Vikas Chowdhry, MS, MBA, is PCCI’s Chief Analytics and Information Officer with more than 15 years of healthcare experience. He works closely with data science and clinical teams at PCCI to develop machine learning driven technologies and products that can empower clinical and social services providers and individuals to create communities that are healthier and more productive. Vikas would like to thank the teams at Parkland and PCCI who helped him understand the nuances and impact ofSDoH on the people served by Parkland. Vikas would also like to thank NatashaGoburdhun from NDGB Advisors who contributed to this post.

[1]; accessed on July 19, 2019

[2] Strengthening resilience: a priority shared by Health 2020 and the Sustainable Development Goals; World Health Organization, Regional Office for Europe;, accessed July 18, 2019

[3]; accessed on July 18, 2019


30 December 2019

SDOH: Better management of high utilizers and the impact on the overall costs of care

For safety-net healthcare systems, helping patients with social needs such as transportation, food or housing, just makes sense from a mission perspective. But when it comes to creating a business case, it gets more complicated.

A recent Kaufman Hall survey of CFOs cited cost reduction, managing changing payment models and improving performance management as the top three challenges for health systems. So, while research may show impacts on costs and utilization from interventions that address social determinants of Health (SDoH), some organizations may not be willing to take the risk of investing in strategies that are outside their scope of service and may not show immediate financial returns. But I would argue that the impact of social determinants of health are everywhere in current health system operations and costs.

“High-utilizers”, individuals who suffer from a multitude of chronic diseases and often complex social/economic challenges, require intensive primary care, and frequently have issues with access, often gain the attention of financial and operational leadership, particularly if the organization has value-based contracts or large uninsured populations. In my experience, to truly manage this population requires addressing the upstream issues that are preventing them from leading and maintaining a healthy life. But with limited resources and time, health systems need to develop a clear strategy by understanding exactly which individuals to treat, and what intervention will best address their healthcare and social needs.

As a practicing clinician, I believe the critical success factor in developing this strategy is leveraging data science and technology to conduct a comprehensive data analysis of the target population.

    1. Analyze claims, clinical, social and economic data from your community at the individual and block level, to determine what social determinants are most impacting your high-utilizer population, such as lack of transportation, food insecurity etc. Finding key contributing factors and root-cause issues for your target population is critical.
    2. Test interventions that other health systems have found lead to improved cost savings and health outcomes. Start with issues with available solutions like transportation, referrals to food banks, and housing services.
    3. Engage external partners to help you execute the intervention, particularly social services and community-based organizations (CBO) that have expertise in addressing social needs, through a collaboration with a comprehensive governance model.
    4. Measure outcomes and adjust strategies as needed.

Scale your initial interventions to other populations, and/or move to more complex social needs.

While some health systems may not be ready to dive into a SDoH strategy, but many realize that the cost of social determinants could already be impacting their daily operations:

1. High No-Show Rates in Clinics

Average no show rates in primary care clinics are 19% with specialty clinics rates running higher, with an average cost between $125 to $350 [1].  That can add up over the course of a year to significant revenue loss for health systems. Lack of transportation or access to affordable daycare play a big role in no show rates among other SDoH. An estimated 3.6 million people missed medical treatment due to transportation issues [2].

While many health systems and health plans have implemented programs with rideshare companies to solve this problem with some success [3]. Targeting the precise patient population that will benefit from rideshare services is critical. In addition to integrating and aligning transportation services for high-need patients, health systems should also explore other emerging technology and non-traditional option to bring services to where residents already are, instead of attempting to find ways to bring them to traditional healthcare access sites. For example, use of telemedicine and digital health as well as deployment of health services in non-traditional settings such as food pantries and or other CBO settings.

2. Unnecessary Emergency Department Utilization for Vulnerable Populations

 Dallas has the fifth highest city jail population, and emerging research suggests that underlying social, behavioral and health issues, particularly substance use disorders and mental illness, contribute to incarceration and recidivism, and that treatment, combined with seamless care continuity for individuals when they return to communities, can help prevent both [4]. Parkland Health and hospital system is designated care provider for this vulnerable population in Dallas. While inmates receive healthcare through Parkland Jail Health program, upon release many former inmates end up without support and in the Parkland emergency department (ED) to seek treatment, driving up unnecessary utilization and costs.

To prevent unnecessary ED visits or a return to jail, Parkland and PCCI are developing an intelligent discharge tool and predictive risk score, combining clinical, social (housing, transportation, job training access) and behavioral factors for inmates, to help connect those being released to community resources. We are also digitally the jail health, clinical providers and community providers on one secure technology platform to better generate real-time cross-sector referrals, track utilization and follow-up, and document services. As a result, transition plans for inmates will comprehensively incorporate medical, employment and financial support like resources.

3. Manage Transitions of Care

Hospitals across the country often struggle with providing homeless patients transitional care to post-acute care facility. If an appropriate place cannot be found, many of these patients stay in the hospital longer than necessary, increasing unnecessary inpatient utilization. And there are no signs of this issue abating anytime soon. In California, hospitals discharged homeless patients nearly 100,000 times in 2017, a 28% increase over 2015.

Two different programs in California have sought to mitigate these issues for hospitals and to assist patients with their social needs. In Los Angeles, the National Health Foundation opened a 62-bed facility for discharged hospital patients who needed less intensive medical oversight than a nursing home. At the facilities, patients have access to case managers for assistance with transportation, food and permanent housing. Area hospitals will often reserve beds at the facility for homeless patients, and L.A. Care Health Plan also leases beds there for their members.

In San Jose, Santa Clara Valley Medical Center created a one-year partnership with Skyline Health Center, a local nursing home. Skyline allocates fifteen beds to the hospital for homeless patients or patients who have no one to care for them at home. During the first ten months, 55 patients were sent to Skyline, and 42 were discharged, the majority to long-term housing programs or family members and friends. Of those discharged, only six were readmitted, a low number for this population [5].

About Manjula Julka 

Manjula Julka, MD, MBA is the Vice President of Clinical Innovation.  Dr. Julka would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.




[4] Healthcare Plays Vital Role in Reducing Recidivism;; November 2, 2017;; accessed July 14, 2019.



14 November 2019

Creating a New Community Integrated Health System – Role of the Traditional Health Provider

By Leslie Wainwright, PhD, Chief Funding and Innovation Officer

Addressing the social determinants of health (SDoH) in communities is a hot topic of conversation in healthcare. The industry has bought into the theory that 20 percent of an individual’s health is determined by clinical care and the rest by social, economic, genetic and behavioral factors. But perhaps more importantly health systems need to recognize that they can’t solve this issue on their own.

From my perspective at PCCI, I’ve seen an increase in value-based contracting models in recent years, and health systems and physicians are looking beyond the four walls of their institutions to build relationships with outpatient, behavioral health, post-acute care, and now non-medical providers. The number and types of collaboratives between health systems and non-traditional providers has been growing over the past several years with a recent report gathering information on over 200 different partnerships between hospital and community-based organizations across the country.

But while health systems may be embracing community provider relationships, I believe that sustainable success in addressing social determinants of health requires a fundamental shift in the way health systems view their role in improving the health of their communities.

Over the past ten to fifteen years there has been an evolution in how health systems have approached improving health outcomes. Initially health systems focused on providing high-tech solutions for care delivery such as robotic surgery, and advanced imaging techniques. Then to meet the need for increased access and demand for outpatient services, health systems seeded service areas with ambulatory surgery centers, urgent care, retail clinics, and physician offices.

In each of these evolutions the strategies centered on a solution created by the health system alone. And one could argue that the main beneficiaries of these investments were often the health systems themselves – increased market share, improved reimbursements. But such a self-centered approach will not work when addressing social determinants where the root causes lie outside the four walls of the health system.

Effectively creating a System of Community will require a collaborative mentality from health systems. While they may have power and influence to gather partners to the table, execution of successful interventions lies with social services and community-based organizations that are the experts in understanding and helping individuals address social needs.  Even if not leading, health systems should still be active participants in this work. Indeed, there are areas where their contributions to the organization of partners is critical:

  • Community Health Needs Assessment

CHNAs, which all health systems are required to complete, can be a starting point for developing strategies to address social determinants of health by quantitatively and qualitatively identifying the needs of the local community. To supplement the CHNA, additional SDoH data should be incorporated to help identify needs at the block level which can help pinpoint exactly where an intervention will likely make the most impact.  These enhanced data should map and evaluate SDoH needs at the block, not zip code level, and should be supplemented with qualitative surveys to understand capacity for self-care, isolation, and learned helplessness across individuals and community.

  • Governance Structure

At the core of any collaborative with community partners should be a formal governance structure that defines the policies and documentation that will enable partners to execute and measure success of their strategic interventions. A formal governance structure can also ensure that all partners have a voice at the table and may help to mitigate any fears that community organizations have that the health system is in control of the initiative.

  • Legal Structure and Data Sharing

Now more than ever, technology, and indeed cloud technology, can connect disparate partners across multiple settings to exchange, share and report on data about the same community members. But there are significant legal and compliance requirements involved in sharing data across entities. Health systems have the expertise to ensure that policies around data sharing are in accordance with Medicare and HIPAA regulations. Health system experts in data privacy and security can provide advice and support to community-based providers in developing policies and procedures required to share data securely.

Improving patient engagement is at the top of the list of priorities for most health systems. The only way that a health system can achieve this is by creating strategies that start and end with the needs of the community. To find success in addressing social determinants of health, health systems will need to cede control and the notion that they need to create, lead and execute the strategy alone.


The Connected Communities of Care (CCC) platform was first implemented in Dallas in 2014 and serves as a comprehensive foundation for partnership by leveraging a web-based information exchange/case management software platform providing seamless connection and coordination between healthcare providers and a wide array of community-based social service organizations.

Since its inception, more than one million services have been documented and more than 215,000 unique individuals who have been impacted by a network of six health care systems and over 100 community-based organizations. The novel approach to addressing SDoH and organizing cross sector information sharing through sophisticated connections has garnered national recognition and has made a lasting impact in Dallas.

Not only has this collaboration connected existing organizations in a new system of community health, it has also changed the way health systems define competitors vs. collaborators. Local health systems that may have viewed each other as competitors for services, have recognized that prioritizing the needs of the community through collaboration makes a stronger impact than any isolated intervention.


About Leslie Wainwright

Leslie Wainwright, PhD., is the Chief Funding and Innovation Officer at Parkland Center for Clinical Innovation (PCCI). She is passionate about entrepreneurship and innovation, and has experience that spans academic research, pharma/biotechnology and healthcare delivery.

Dr. Wainwright would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.


28 October 2019

SDoH: From Theory to Action – Making Social Determinants of Health a Reality

By Steve Miff, PhD, President & CEO of PCCI

The term “social determinants of health” is far more than a trendy new buzzword in health care. Serving the physical, mental and social needs of the community is not just the right thing to do but can mean substantial improvement in care and reduction in unnecessary healthcare costs.

Several studies have shown that addressing social needs, such as food or housing insecurity, can have a significant impact on a person’s healthcare outcomes and costs. Individuals experiencing housing insecurity or homelessness have higher rates of chronic diseases such as high blood pressure, heart disease, diabetes, asthma, chronic bronchitis, and HIV.  This in turn leads to higher utilization of healthcare services such as emergency room visits, inpatient hospitalization and longer lengths of stay compared to those individuals with secure housing. Similar results are seen in those experiencing food insecurity.

Hospitals often state that part of their mission is to provide high quality care and improve the community’s health, or community benefit. A recent study of hospital mission statements in three states (Ohio, Florida and Texas) found that while quality was cited most often (65%), the second most frequently used term was community benefit (24%).[1]  If community benefit or community health is part of your health system’s mission statement, how much are you really doing to address the whole health of a community vs. just addressing their “sickness” needs?

At PCCI, our combination of data scientists and expert clinicians believe that health systems have an obligation to address social determinants of health to ultimately remove the disparities and inequality that we see in our community’s health. Yet this is tricky because success requires outreach skills, community relationships and data insights that extend beyond the traditional promise of health-related services. That said, there are three key elements that can assist health systems in making an investment in social determinants of health a reality. In order to move from theory to action, my suggestion is that health systems do the following:

1. Leverage the board’s community presence to align on areas of greatest need

As part of health system leadership, board members ensure alignment between mission and a defined SDoH strategy at all levels of the organization. As community representatives themselves, board members can also create the momentum and connections that health systems need to bring community and business partners together to create a governance structure for launching a connected community of care.  Such governance structure will guide the strategy, legal and policy needs, and the investment and execution of a connected and aligned SDoH strategy.

2. Invest in long-term partnerships to ensure sustainability

Recognize that as health systems, you alone cannot solve for social determinants. To truly meet the social, behavioral and emotional needs of some of the most vulnerable individuals in your community, you need to identify community partners with expertise in these areas. With the assistance of board members, assemble a partnership collaborative, with a formal governance structure, to build community-based strategies around SDoH needs. Support the sustainability of this collaborative with technology and data science techniques to identify specific root causes of social need in target populations, share data, and measure impact of interventions.  Identify an independent partner to evaluate the effectively of the SDoH initiatives and measure the cost, savings and impact across the community and for the health system.

3. Develop your own financial models that demonstrate the impact of SDoH

Between 2000 and 2017, hospitals and health systems across the country spent $620 billion in uncompensated care. We propose that health systems create an internal “at-risk” ACO-like model for their uninsured population and invested just five to ten percent of their annual uncompensated care dollars in developing community engagement programs to address social determinants of health.  These systems would see a three to four-fold return by addressing upstream, root causes in the community and increasing preventive, social and emotional support services to individuals in the community.


Texas Health Resources (THR), a 29-hospital faith-based non-profit health system based in Arlington, Texas has supported their mission “To improve the health of the people in the communities we serve” by creating a ten-year strategic plan to move from a hospital- to a patient-centric to a population health-focused organization. The THR board of directors has been an integral part of overseeing every step of the strategy to ensure that there is measurable and sustainable improvement in their community’s health.

Data and information gathered from regular Community Health Needs Assessments, has led to the creation of more than 200 non-profit partners across the region, including formal agreements with the American Cancer Society, American Diabetes Association and the March of Dimes, to increase health and well-being through programs focused on behavioral health, chronic disease management, child automobile safety, healthy eating, and provision of low-cost mammograms.

Board committees regularly monitor progress toward strategic goals and receive input from local community health councils and entity boards. But this commitment to community health is not just at the leadership level, employees of THR can spend between 8-12 hours of paid time annually to volunteer at local or THR sponsored community organizations to support community health efforts.

Most recently, THR announced a new initiative called Texas Health Community Impact which employed a data-driven, outcome-focused approach to identify areas of need in their communities. Mental health was indicated as a priority through the community health assessment. Zip code level data analysis and qualitative research helped them identify specific areas where seniors and youth lacked access to food and were also isolated, which led to depression and physical problems. As a result of this work, THR will distribute $5.2 million in grants to twelve agencies that will focus on interventions for these issues.

These grants only represent a portion of the financial investment that THR has made to its communities. In 2017 they provided $362.5 million in charity care, $31 million to community benefit programs and in volunteer hours, and $456.6 million in unreimbursed Medicare services.[2]

[1] Cronin, CE, Bolon, DS. Comparing Hospital Mission Statement Content in a Changing Healthcare Field. Hosp Top. 2018 Jan-Mar;96(1):28-34.



About Steve Miff

Steve Miff, PhD., is the President and CEO of Parkland Center for Clinical Innovation (PCCI). He is a seasoned executive with more than 20 years of experience in healthcare analytics and consulting. He has served in various leadership positions in technology/consulting start-ups and on multiple boards. Dr. Miff is a recognized national thought leader with over 100 peered-reviewed and independent thought leadership publications.

Dr. Miff would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.





17 July 2019

Reducing “Misbehaving” In Healthcare Operations Through Data and Optimal System Design

By Manjula Julka, MD, MBA and Albert Karam, MS

Every year, people throw away millions of dollars when they decide to fill up their car tanks with more expensive premium gas when regular unleaded will do just fine for their cars.

There are several reasons for that kind of sub-optimal behavior. Nobel Laureate and University of Chicago professor Richard Thaler calls it — “misbehavior”. Thaler, in his book “says that the optimization problems that ordinary people confront are often too hard for them to solve, or even come close to solving. Thaler’s two friends and mentors, Amos Tversky and Daniel Kahneman (himself a Noble Laureate) have illuminated several pathways on how we make decisions. Kahneman’s book “” articulates some of them and one of their decision theories may have applicability here. They say that when people make decisions, they do not seek to maximize utility. They seek to minimize regret. So, in this case, among other things, perhaps people are thinking that “better not regret causing any damage to the car for a few pennies”, not realizing that those pennies add up and that there’s no damage being caused.

Regardless of the root cause though, one of the ways to minimize these behaviors is to use data to educate and frame choices (the famous “nudge”) to make the optimal decision the easier one to make (through appropriate defaults etc.). And we see these kinds of suboptimal behaviors play out in every walk of our lives and healthcare is no exception.

At PCCI, we recently had an opportunity to work with a group of passionate clinicians at Parkland Health and Hospital System regarding a very similar issue. Magnesium is a key mineral for body functionality especially for heart, nerve, muscle and protein synthesis. Monitored in most hospitalized patients, it is often replenished to maintain normal levels. With very few exceptions, oral Magnesium is as effective as intravenous (IV) Magnesium medication with the added value of being significantly less expensive and more comfortable for patient (think premier gas versus regular unleaded). However, for a variety of reasons, the primary route of ordering Mg was through IV. To understand the magnitude of the problem at hand (and potential savings), we used Parkland’s EHR system (Epic) to identify instances where oral Mg could be as effective as IV Mg and realized that simply by changing the route for appropriate patients, the system could save hundreds of thousands of dollars. This analysis led to system-wide effort to provide informational messages to clinicians at point of care in the ordering process via the EHR so that they could make a more informed choice.

This initiative is a great example of how innovation, changes in behavior and optimal choices happen at the intersection of analytics, data and human behavior and psychology. Every care team member wants to provide the best care for patients, but sometimes the cumulative impact of individual decisions is lost. The conversion of one single IV order at a time to oral magnesium multiplied across many clinicians is now saving thousands of dollars to the hospital system while improving evidence-based care.

For additional technical details, please see 

12 June 2019

The Time Is Now for Health Systems to Get Serious About Social Determinants of Health

A fundamental question continuing to face many health system executives is: How do we comprehensively address the needs of patients when those needs extend beyond the boundaries of traditional clinical care?  As President and CEO of PCCI, we have been focusing on this very challenge since 2012.  And while there has been much talk and excitement about social determinants of health (SDOH), we believe that ~90% of the health system market still does not leverage social/economic information when designing population health programs, developing patient-specific treatment plans, locating new services, or conducting community needs assessments. But before health system executives can design an effective SDOH strategy for their organizations, they must first assess where they are and where they would like to be based on the insights and advantages a progressive SDOH strategy would offer. PCCI’s Social Determinants of Health Maturity Model can help executives take this critical step.

Social Determinants of Health Maturity Model

Level Zero: Incomplete Picture of an Individual’s Environment

Realistically, this is the starting baseline for most organizations. Often, teams will attempt to use clinical and claims data ALONE as a means to segment patient populations and project the impact on a patient or cohort. This rarely works; rather, it often leads to late treatment in acute environments, sub-optimal interventions, and erroneous insights about specific patients, patient populations, or geographic markets.

Level 1: High-Level View of SDOH, Using Specific Social and Economic Indicators as Proxies

Teams can extract basic information from claims or clinical data that could serve as effective SDOH proxies. An example would be to look at the number of changes in addresses in a specific record, over a 12-month period, as a strong indicator of housing instability.  At the highest level, teasing out information from existing records can begin to illuminate some of the critical social and economic challenges that may present for individuals in a given community. This level of insight also allows health- system teams to test basic assumptions about a market. We’ve seen teams fooled when the employment level appears to be relatively stable, only to subsequently discover that much of the employment is via low-wage jobs with very poor benefits.  If you begin to see that people are moving around even though the employment statistic looks stable, you begin to realize that the actual stability of your community might not be what you perceived it to be.

If at Level 1, Leadership Teams Should Be:

  • Developing high-level proxy indicators to reflect underlying social and economic challenges that could play a significant role in health status or the ability to access services.
  • Understanding the payer mix; who you serve and, even within the insured population, understand the wage/income levels because there is a high percentage of employed, low-wage individuals that have vulnerabilities associated with transportation, housing, affordable daycare, etc.
  • Becoming familiar with existing local or state connected communities of care programs or activities aligning providers and community-based organizations, such as food pantries, to streamline assistance efforts, reduce repeat crises and emergency funding requests, help address disparities of care, and improve the health, safety, and well-being of residents.

Level 2: Root Causes Understanding of Poor Outcomes at the Population Level

The rubber hits the road at level 2 and teams begin leveraging local data that directly reflect variation in social determinants. We believe that to understand root causes and build actionable models for patient engagement and support, you must evaluate data at the block level. Zip-code level aggregation often masks important details. This is particularly true in highly populated municipalities that can see a tremendous amount of social determinant variation within a 0.1 mile distance. For example, if I had block-level information providing insight that a six-block neighborhood within my market was having transportation-oriented issues and concentrated pockets of non-violent crime, I would model these insights into the deployment of my mobile diagnostic clinics or my development of innovative models to improve access.  Also, if I was discharging a patient who resided in that neighborhood, I would rethink how to schedule follow-up appointments, since the chances of the patient keeping the visits are extremely low. This level of insight and actionability would be missed at the zip-code level.

In collaboration with DFWHC Foundation, Community Council of Greater Dallas, and the University of Texas at Dallas, PCCI built a platform for Dallas called Dallas Community Data for Action and/or Community Data Insights [CDI].  CDI ingests and organizes multiple, publicly available data inputs, such as housing, education, food availability, and 911 and 311 data to generate real-time, actionable dashboards containing over 60 factors that all point to specific social determinants.  In Dallas, use of this data has been vital in understanding pockets of need and in locating areas where the impact of interventions can be the most profound.  You can also use this data more broadly to generate support to build community cross-sector collaboration, by enabling health systems to effectively  engage and coordinate with local municipality officials on community-based support services and planning, and also by helping philanthropic organizations to better understand (and track) community needs in order to invest in/prioritize funding areas that will produce the greatest impact.  In addition to having a detailed and dynamic picture of social and economic needs (demand for services), the CDI dashboard can quickly map out where support services are available/delivered and map/model the interdependencies and concentration of chronic health conditions with social support needs.  As this model is rapidly scalable, PCCI is already working with others across the country.

If at Level 2, Leadership Teams Should Be:

  • Integrating SDOH market insights into your strategic planning process and your community engagement plan
    • Use block-level SDOH in community needs assessments
  • Anticipating and predicting the correlations between multiple social and economic factors to inform your patient flow and access strategy (including your telehealth strategy). Start conducting trend analyses to anticipate and forecast the changes in local-market dynamics that will impact utilization, payer mix, and social/economic barriers to health.
  • Crafting a data-driven engagement plan to align more directly with local municipalities and local philanthropic organizations.

Level 3: Comprehensive Partnership Between a Community’s Clinical and Social Sectors

Participating organizations across a community are collaborating on one Information Exchange Platform and are connected through an innovative closed-loop referral system allowing them to communicate and share information with each other. Success at this highest level requires both a strong technology infrastructure and consistent programmatic deployment [at scale] across a community. This is what we’ve done in Dallas with our technology partners at Pieces Technology Inc.; effectively managing the right balance of people, processes, and technology has allowed us to achieve the positive results that we’ve seen.

Level 3 means a significant investment and a multi-year commitment, not only by the anchoring healthcare system or systems, but also by the local community.  It requires an initial investment and a robust sustainability plan that can ensure that the platform capabilities evolve with the changing needs of the community.  Deployment requires not only new technology, but an engaged local governance structure, new legal and data sharing agreements, and further refinement of data integration and advanced analytics at the individual level.  Integrating these into new/updated clinical and community workflows enables teams to proactively predict specific health and social/economic needs, the complexity and co-dependency of needs, and the ability to act real time at the point of care to address these needs.  This can facilitate making real-time referrals for community support services, tracking whether individuals accessed suggested medical or community resources (and what specific services were provided), and measuring and tracking the impact to individual/community resiliency, self-sustainability, health outcomes, and cost.  In Dallas, we’ve also started to leverage advanced data algorithms to risk-stratify individuals based on their health and social/economic needs to better prioritize and tailor resources and to proactively target high-risk individuals for engagement and follow-up via digital technology.

At levels 2 and 3, a health system must also think about how to leverage its foundation resources and internal employee community-outreach volunteer programs.  Once you better understand the patients that you’re serving in your market and the community-based services they access, you can better deploy employee-based efforts and philanthropic activities that align with the strategic efforts and provide maximal impact.

If at Level 3, Leadership Teams Should Be:

  • Crafting the information exchange platform governance infrastructure to delineate key roles, essential participants, and shared objectives.
  • Committing to cross-community collaboration [potentially including competitors] and a long-term effort; recognizing that your health system might be an anchor organization, but it cannot independently solve the entire problem.
  • Selecting and deploying the technology infrastructure [Pieces Iris™, TAVHealth, Unite Us, etc.] to enable cross-community engagement.  Develop updated clinical and community-based workflows.

In summary, if you’re just starting to address SDOH, you’re late.  It is critical for health systems to begin their SDOH journey today, especially if you serve a vulnerable population and/or operate in a market dominated by uninsured and Medicaid patients.  Addressing SDOH is also equally important for organizations managing a lower-wage, commercially insured population and for any health system that is actively managing or considering taking on risk-based contracts.

If you’re well on your way up the SDOH curve and actively integrating SDOH into your strategic and care-delivery models, then start working on new models to bridge social isolation (physical and mental) and to better understand (and develop strategies to address) challenging behaviors, including chronic helplessness.

To learn more about our Dallas journey, please visit our website and see what our team of PCCI experts is doing to make a difference or visit our technology partners at Pieces Technology to experience the Pieces IRIS™ technology.

14 November 2018

World Diabetes Day

Today, November 14, is designated as World Diabetes Day to unite the global diabetes community to produce a powerful voice for diabetes awareness and advocacy. According to the World Health Organization (WHO), over 425 million people are currently living with diabetes, prevalence is continuing to rise, and one in two people currently living with diabetes is undiagnosed.

Living with diabetes is a daily struggle, but many organizations have worked to create programs to decrease the struggle of those impacted. Ms. F, a 62-year-old African-American female with diabetes who relies on getting her nutrition from a food pantry, is a great example of someone that has benefited from these programs. Ms. F struggled with making proper food choices, adherence to proper medication, and transportation to make regular doctors’ appointments.

Through part of PCCI’s Connected Communities of Care program which shares patient’s information between providers and community-based organizations, Ms. F’s health and social service providers were able to connect and share information regarding her condition. When Ms. F visited the food pantry, staff members were aware of her diabetes. This knowledge enabled the staff to effectively guide her through her diet choices. This pilot program between three food pantries and Parkland Health & Hospital system helped many patients in taking the steps needed to control their disease.

In addition to limited access to healthy food choices, many patients in underserved communities have limited access to transportation. This challenge has made the remote monitoring of patients a critically important component in managing diabetes. PCCI is partnering with Parkland Health & Hospital System’s Global Diabetes Initiative to explore innovative approaches to improving the care of diabetic patients with foot ulcers which can lead to amputations if unresponsive to care. By acquiring data from home glucose monitoring devices and making real-time changes to treatment without physically having to see the patient, the (soon to be launched) study aims to create a sustainable remote glucose monitoring care system. This system will improve glucose control, promote faster healing of foot wound, and reduce long-term healthcare utilization and ultimately, reduce the burden cost of care for individuals and families.


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