“BUILDING CONNECTED COMMUNITIES OF CARE” BOOK EXCERPT Case Study – Engaging Patients—Location and Relationships Matter

Following is an excerpt from PCCI’s book, “Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations.” This is a practical how-to guide for clinical, community, and government, population health leaders interested in building connected clinical-community (CCC) services.

This section is from Chapter 6, “Clinical Providers Track.” The purpose of the Clinical Providers Track is to set out the stakeholders and processes required to integrate clinical entities, insights, programs, interventions, strategies, and measurement for the 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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Case Study: Engaging Patients—Location and Relationships Matter

As part of our CCC history, PCCI has developed and tested a number of approaches to identifying individuals within the population of vulnerable and under-served Parkland patients who could benefit from screening for health related social determinants, engaging them in the completion of a brief risk assessment and subsequent linkage to available community resources. As with many of the elements of the CCC, this proved to be a learning experience in which initial, more conventional approaches gave way to new and more innovative approaches of engaging this population to optimize goal
attainment.

RECRUITMENT
Much of the initial work began with screening in the outpatient setting. Parkland has 12 Community-Oriented Primary Care (COPC) clinics located throughout Dallas County to serve local residents. Because the COPCs see a large number of patients on a daily basis, many of whom are considered vulnerable and underserved, these COPCs were determined to be a great
location to conduct the social determinant risk assessments. When a patient checked in for a visit, the office staff would provide the patient with a paper-based screening tool to self-administer. Trained community health workers were available in the waiting area to help, if required. Initially we felt like this approach made sense since the large number of COPC patients translated into large numbers of completed screening surveys. However, while there were a large number of initial screenings, the number was very low of patients that agreed to engage with a PCCI community health worker to connect with local community services. Many stated they were not interested or needed to leave the facility for another commitment. Other patients completed the needs assessment but left the COPC before staff members were able to connect with them. Of these, very few responded to follow-up phone outreach and the ones that did were hesitant about referral to community-based services. The team attributed this gap to the lack of personal engagement at the point of initial screening.

As a result of this initial experience, the team made some changes to the screening protocols. Three concurrent workflows focusing on different points of patient encounters were designed and tested. The three new points included: (1) engagement while the individual was in the ED, (2) engagement of individuals that had already left the ED, and (3) engagement of hospitalized patients on the medical/surgical floors of the hospital.

For the direct engagement while the individual was in the ED, licensed social workers conducted initial face-to-face screenings with patients awaiting care. The social workers were provided a list of eligible patients (those with multiple ED visits in the past year) and went room to room to conduct the screenings and determine if the patients were interested in connecting with community resources. Because many of these patient interactions took place while the individual was in the middle of an ED care visit, the PCCI team member was mindful of this and stepped aside, as needed, to ensure they didn’t interrupt the patient’s care. For those individuals that left the ED before screening, the PCCI team placed these individuals’ names and contact numbers on a sheet and later reached out to them by phone to explain the program and ask if they were interested in receiving information on community resources.

Finally, for those individuals undergoing an inpatient stay in the hospital, PCCI personnel obtained census data reports with information about eligible patients and then staff visited these patients in their rooms to conduct one-on-one conversations to implement the screening tool and to determine if the patients were interested in receiving more information about navigation services to community resources.


As shown in Table 6.1, a key learning from this undertaking was that the site matters in conducting the screenings and successfully connecting people to local programs for support. We learned that engaging patients during their inpatient stay was the optimal care setting in which to conduct screenings and then connect those patients to the appropriate community resources.

Establishing trust with patients early in the process was essential, both for completing the initial screening tool and for facilitating connection to community services. During our initial approach, we relied on self-administered screenings that provided little in the way of opportunity to establish a relationship with patients. Our modified workflow allowed our social workers and community health workers to verbally administer the screening tool and provide additional explanations as part of that exchange. This process also made the transition to navigation services virtually seamless and much more
effective. Feedback from patients has also been positive; most indicated that the information received was useful and many said they would share this information with other family members and close friends.

THE SCREENING PROCESS
The PCCI community engagement team consisted of six community health workers and two master’s-level, licensed social workers. Initially, the team consisted entirely of social workers, but our experience taught us that a blended staff model was more cost-effective. PCCI physician leaders coached all team members on how to be flexible and professional when working in the ED, where care moves at a rapid pace. The team needed to take cues from medical staff on where and when to step in to conduct the screenings. Similar trainings were delivered to those staff visiting patients in the hospital.

Over the course of the 6-month pilot, we were also able to identify a number of key elements that increased both the effectiveness and efficiency of the screening process. For example, we learned that it took on average 15 minutes to complete the assessment tool when it was facilitated by a team member but only 10 minutes when self-administered. While the self-administered survey took less time to complete, we found a much higher percentage of incomplete and inaccurate responses, making many of the screens useless. As would be expected, we also found that older patients—those 65 or older—took on average 20 minutes to complete the facilitated screening survey while younger individuals completed it in half the time. The difference was attributable to the amount of questions asked and attendant conversations, which were much more prevalent with older patients. Finally, once we began to work more closely with the patients and they developed a better sense of the purpose of the work, we encountered very few issues with obtaining consent from the patients to share their information with others.

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COVID-19 fatalities become the leading cause of death in Dallas County one year into the pandemic 

Dallas – With the anniversary of Dallas County’s first COVID-19 death having recently passed, mortalities due to the pandemic has become the leading cause of death among county residents, surpassing heart disease, cancer and strokes in the past year.

According to the Centers for Disease Control and Prevention (CDC), the first death in Dallas County was recorded on March 19, 2020. By March 21, 2021, deaths in Dallas County from COVID-19 stood at 3,763. This surpassed estimated deaths due to heart disease (3,668), cancer (3,356) and strokes (1,015) during that same period.

COVID-19 deaths in Dallas County saw their steepest increases starting in December. On Dec. 21, 2020, deaths due to COVID-19 stood at 1,841, but in the following three months deaths more than doubled, adding 1,922 more casualties.

“This is a sad milestone for Dallas County,” said Vikas Chowdhry, MBA, Chief Analytics and Information Officer at PCCI. “We can see that COVID-19 claimed the most lives following social gatherings and holiday travel beginning with Thanksgiving through Christmas and New Year’s. Starting in December we saw a startling spike of deaths due to COVID-19 that represented more than all of the deaths in the previous months we had experienced during the pandemic. This offers a valuable lesson going forward, that we must remain vigilant to protect ourselves, our families and friends.”

PCCI recently forecast that Dallas County may reach COVID-19 herd immunity by mid-June. However, in order to reach this threshold residents of Dallas County need to continue their efforts to protect themselves from infection. “We are remaining optimistic that we can reach herd immunity by the early summer, but the key is ongoing vigilance, including continued adhering to local health official guidance, social distancing, face covering, and registering for vaccinations as soon as possible,” said Chowdhry.

An animated graphic showing the evolution of the COVID-19 mortality rate in Dallas County can be viewed at https://covid-analytics-pccinnovation.hub.arcgis.com/, PCCI’s COVID-19 Hub for the region. This shows total COVID-19 deaths by day, based on data provided by the New York Times COVID-19 data tracking project. The mortality data includes both confirmed cases, based on laboratory testing and probable cases, based on specific criteria for symptom and exposure. This is per guidance form the Council of State and Territorial Epidemiologists.*

To help protect Dallas County residents, PCCI recently launched the MyPCI App, a web-based program to help inform the residents of Dallas County to their individual risks. The MyPCI App, free to register and use, is a secure, cloud-based tool that doesn’t require personal health information and doesn’t track an individual’s mobile phone data. Instead, it is a sophisticated machine learning algorithm, geomapping and hot-spotting technology that uses daily updated data from the Dallas County Health and Human Services (DCHHS) on confirmed positive COVID-19 cases and the population density in a given neighborhood. Based on density and distances to those nearby who are infected, the MyPCI App generates a dynamic personal risk score.

To use the MyPCI App, go to, https://pcci1.wpengine.com/mypci/, click on the link and register (Using code: GP-7xI6QT). Registration includes a request for individual location information that will be used only for generating a risk assessment, never shared. Once registered, simply login daily and a COVID-19 personal risk level score will be provided along with information to help individuals make informed decisions about how to manage their risk.

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 Non Medical Drivers 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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*The tallies reported here include probable and confirmed cases and deaths. Confirmed cases and deaths, which are widely considered to be an undercount of the true toll, are counts of individuals whose coronavirus infections were confirmed by a molecular laboratory test. Probable cases and deaths count individuals who meet criteria for other types of testing, symptoms and exposure, as developed by national and local governments.

Governance: The Glue That Holds Connected Communities of Care Together

By Keith C. Kosel, PhD, MHSA, MBA

Aligning groups that have very different backgrounds and agendas, for the good of the community, is no easy matter. Whether at the city, state, or federal level, governmental or civic entities are tasked with trying to build consensus among various stakeholder groups to affect an outcome that works for the constituents they represent. It is no different for those tasked with leading a Connected Community of Care (CCC).

The Role of Governance
The premise behind the CCC is that by bringing together healthcare providers, community-based social service organizations (CBOs), faith-based organizations, and various civic entities, a community can establish a network of care providers focused on addressing residents’ social and/or clinical needs. While the premise is straightforward, establishing the governance group and governance structure to set up and manage a CCC is anything but straightforward. Before we look at how we might bring entities with different missions and agendas to the table, let’s understand what we mean by a governance group and a governance structure, and why these are essential to form a successful CCC.

The nucleus of a CCC is its governance group― those organizations that have come together to establish the CCC and to form the rules by which it will operate (the governance structure). As most CCCs form from scratch, the governance group is typically made up of one or two organizations we refer to as Anchor Organizations. These are typically large, well-established, and highly respected organizations within the community. They could include national social service organizations such as the United Way or Salvation Army, or they could be philanthropic funders, faith-based organizations or healthcare systems. What all these organizations have in common is a mission to improve the health and well-being of their community’s residents. As such they lie at the heart of the governance group (Figure 1).

Figure 1. Connected Communities of Care Including Governance Structure

In addition to the Anchor Organizations, the governance group typically consists of four to six additional Partner Organizations. These may be somewhat smaller CBOs (in scale and scope), but they all play a foundational community role in addressing resident’s social and/or clinical needs. Partner Organizations are well-known within the community and historically work closely with the Anchor Organizations. Partners could be regional food banks, housing assistance providers, crisis centers, mental health providers, local school districts, etc.― all defined by the fact they deliver essential social or clinical services within the community.

The role of the governance group is to provide structure and guidance for the CCC. By structure we mean things like: (1) how network participants will be identified and approved, and what will be expected of each; (2) what the CCC’s mission and charter will include; (3) how the CCC will be funded; and what type of data must be collected and shared, consistent with HIPAA regulations. While the governance structure deals with establishing the rules and policies that guide the day-to-day workings of the CCC, the governance guidance function focuses on issues like: (1) support for a Readiness Assessment (See previous blog) to determine if the community needs― and is even ready for ―a CCC; (2) how and at what rate the CCC should grow; (3) strategic partnerships; and (4) CCC sustainability. A governance group is essential to establishing and growing the CCC. Moreover, without a strong, representative and resilient governance group, most CCCs will eventually fail.

Act 1 -Forming the Governance Group

While we might think that forming the Governance Group would be a fairly easy task, given that many Anchors and Partners already know one other, in reality the process is far more complicated. While many of the Anchor and Partner Organizations work in parallel, they often have a narrow topical focus, such as providing food, housing, healthcare or after-school programs. These topical focus areas may conflict either with regard to the purpose of the work or the process by which the work takes place. As an outsider looking in, we might think these are minor, easily solved issues when in fact they are anything but. Layer on top of this funding mechanisms that often are not uniform or are based on an organization’s own performance to support its mission within the broader CCC, and simple differences compound quickly. As the number of Anchor and Partner Organizations increases, the complexity of achieving alignment among these entities also increases dramatically. This is the point where the presence of a powerful and commanding Anchor Organization(s) become critical in driving alignment.

Because there are usually only one or two Anchor Organizations, the likelihood of disagreement is minimized, compared to the next governance level down (i.e., Partners). Typically, the Anchor Organizations individually have been contemplating a Connected Community of Care for some time and all it takes is the right “spark” at the right moment to bring them together. Further, Anchor Organizations by their nature are well versed in coalition building and working across multiple sectors, which is a skill set that may be less well-developed in the Partners, especially in smaller or rural communities.

A key function of an Anchor Organization is to bring a handful of Partner Organizations into the governance group. Here the Anchor’s skill in selecting collegial partners or ones that can easily be won over to align with the CCC’s mission and goals is extremely important. Including a Partner that will be disruptive or non-cooperative is a fatal error, regardless of what resources that Partner might control. Even if it means working harder to secure the necessary resources, it is better to include only cooperative and committed partners than to access resources at the cost of major disruption.

Act 2 – Moving the Governance Group Forward
Establishing a highly cohesive and well-functioning governance group is only the first step in an ongoing process to grow a successful CCC. The governance group must continue to evolve along with the CCC network. As the network expands, there may be a need to increase representation within the governance group. While warranted, this process must be handled carefully to avoid the disruption just mentioned. At the same time, the governance group may need to remove some participants from the network for failing to follow the CCC’s charter or for sub-standard performance. Although these are difficult decisions, neglecting to make them can irreparably damage the entire CCC over time.

In wrestling with these decisions, the governance group must always be focused on sustainability – sustainability of the CCC and of the governance group itself. Sustainability of the CCC takes different forms from operational sustainability to financial sustainability, each of which are indispensable to a CCC’s long-term growth and viability. Operational sustainability focuses on the challenges of keeping the CCC network up-to-date with regard to technology, strategic partnerships, growth through additional participants, and ongoing social and health needs assessments (i.e., is the prevalence of obesity increasing silently in the community? Are more people accessing utility assistance in the face of declining employment as businesses relocate to more favorable locations?). It also includes provisions for turnover at both the CCC administrative level and at the level of the CBOs, which historically have high turnover levels due to numbers of volunteer staff, etc.

Achieving financial sustainability is the ultimate challenge facing CCC governance groups. Without sustained funding, whether through internal or external means, a CCC cannot survive long term as an effective functioning network. The real challenge is not only securing funding but doing so in a way that benefits all network participants in some fashion based on need and contribution. When network participants must seek funding on their own, inequities are prone to develop, as participants begin to follow their own interests rather than the collective interest of the CCC. Though a difficult challenge, especially in today’s pandemic environment of scarce funding, CCC governance groups must confront it head-on.

CCC governance is not an easy or straight road. Rather it is strewn with potholes, stop signs and detours- but one that must be followed none the less if a CCC is to achieve its goal of improving the health and well-being of the community and its residents. The time and thought that goes into establishing a cohesive and highly effective governance group and structure will pay dividends to the CCC and those it serves many times over as the CCC grows and matures to become a key fixture within the 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 Non Medical Drivers of Health and the impact of community-based interventions in improving the health of vulnerable and under-served populations.

New England Journal of Medicine – Catalyst featured PCCI in article about using data to manage COVID-19

New England Journal of Medicine – Catalyst: The Imperative for Integrating Public Health and Health Care Delivery Systems

NEJM-Catalyst published a column by leaders at Parkland Hospital and Dallas County’s health department about how they used PCCI’s capabilities leveraging data to educate and care for the county’s high-risk population. Click on the link below to read the whole article:

https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0580

 

For the PDF, click here: NEJM Catalyst_Cerise_Proximity Index

PCCI’s Vulnerability Index Records 66 Percent Reduction in COVID-19 Risk for Dallas County

DALLAS – Dallas County saw a massive 66 percent reduction in risk values recorded by PCCI’s COVID-19 Vulnerability Index in February, with some of the most vulnerable ZIP codes showing significant reductions.

One of the hardest hit ZIP Codes, 75211, which includes the areas around Cockrell Hill and Oak Hill, saw its vulnerability risk value drop by 151.9 points, going from 196.9 vulnerability rating in January to 44.9 in February. The 75211 ZIP code remains the second most at risk area in Dallas County, however its overall improvement is a positive sign for the hard-hit area.

“The dramatic drop in the county’s vulnerability is positive and offers a hopeful path going forward,” Thomas Roderick, PhD, Senior Director of Data and Applied Sciences at PCCI. “We are remaining cautious as we saw vulnerability rates come down

last summer only to see increase significantly later. The key to continued reduction of vulnerability is ongoing vigilance, including continued adhering to local health official guidance, social distancing, face covering, and registering for vaccinations as soon as you’re able.”

Launched in June of 2020, PCCI’s Vulnerability Index identifies 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 PCCI COVID-19 Vulnerability Index

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

In addition to the drop in 75211, the ZIP code 75204, in east downtown Dallas, saw a 104.4 drop in its vulnerability ratings. ZIP code 75224, in southern Dallas, saw a drop of 64.9 in its vulnerability ratings, but now is ranked as the most vulnerable area in Dallas County with a vulnerability value of 45.87. Also, the ZIP code 75227, in east Dallas County intersected by State Highway 12, is the third most vulnerable area in Dallas with a 42.45 value, though it dropped 70.5 in its vulnerability ratings since January.

“Holidays and events are potential super-spreader events,” said Dr. Roderick. “We are in a time of year where these tend to

be limited, which impacts ongoing COVID-19 cases. However, Spring Break and occasional holidays on the calendar represent potential trouble times. PCCI will continue monitoring for things that can push Dallas County into higher levels of vulnerability.”

PCCI recently forecast that Dallas County may reach COVID-19 herd immunity by mid-June. This, Dr. Roderick points out, is only possible though vaccinations.

“We each need to be patient as well as register and receive our COVID-19 vaccination,” said Dr. Roderick. “The only way we will reach herd immunity is by maintaining our vigilance and getting vaccinated. Reaching herd immunity is a community effort and should be a priority for each of us.”

PCCI recently launched the MyPCI App, another program to help inform the residents of Dallas County to their individual risks. The MyPCI App, free to register and use, is a secure, cloud-based tool that doesn’t require personal health information and doesn’t track an individual’s mobile phone data. Instead, it is a sophisticated machine learning algorithm, geomapping and hot-spotting technology that uses daily updated data from the Dallas County Health and Human Services (DCHHS) on confirmed positive COVID-19 cases and the population density in a given neighborhood. Based on density and distances to those nearby who are infected, the MyPCI App generates a dynamic personal risk score.

To use the MyPCI App, go to, https://pcci1.wpengine.com/mypci/, click on the link and register (Using code: GP-7xI6QT). Registration includes a request for individual location information that will be used only for generating a risk assessment, never shared. Once registered, simply login daily and a COVID-19 personal risk level score will be provided along with information to help individuals make informed decisions about how to manage their risk.

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 Non Medical Drivers 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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PCCI Forecasts that Dallas County to reach COVID-19 Herd Immunity by mid-June

Dallas, Texas – Parkland Center for Clinical Innovation (PCCI), which improves healthcare for vulnerable populations using advanced data science and clinical experts, estimates Dallas County will reach a critical tipping point of COVID-19 “herd immunity” in late-June due to total case recoveries and vaccinations.

PCCI forecasts that Dallas County is on track to have 80 percent of the county residents at levels of COVID-19 “herd immunity” by early summer. This forecast is based on models estimating individuals who either have recovered from COVID-19 or who have received vaccinations.

“Our forecast is determined by the data, models and trends we have been monitoring and analyzing since the beginning of the pandemic and informed by the latest national and international research. We are optimistic that by early summer, much of Dallas County will reach herd immunity,” said Steve Miff, PhD, President and CEO of PCCI. “We will get to herd immunity either through continued infection, which is a slow route that will continue to harm the community and economy, or vaccinations. This underscores the importance of Dallas County residents registering for and receiving the COVID-19 vaccinations as quickly as possible and continuing to stay vigilant and safe from being infected. We’re also racing to stay ahead of the development and spread of existing or future new COVID-19 strains. We are in this together and will only get there though our collective and combined efforts.”

PCCI’s analysis, as of Feb. 22, indicates that the county has already reached 44 percent of the 1.9 million adult residents of Dallas County as either recovered from COVID-19 or in the process of receiving their full COVID-19 vaccine. That includes 922,460 COVID-19 confirmed and presumed infected and recovered, and 270,642 residents who have received their first (154,766) and second (115,875) vaccine shot.

“Reaching the tipping point for herd immunity is achievable with continued community effort,” said Thomas Roderick, PhD, Senior Director of Data and Applied Sciences at PCCI. “But parts of the county may not share the early benefits in our estimated forecast if they don’t keep pace with vaccines. Vaccines are also the best line of defense against COVID-19 variants, so it is critical that vaccines are made available to as many people as possible and county residents make it a priority to get vaccinated.”

PCCI’s forecast for herd immunity is based on widely accepted statistical analysis of spread and management of diseases within com

munities. Further, PCCI’s 80 percent range for reaching herd immunity is in line with national estimates, such as that of Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases, who recently gave a range of 70 to 90 percent and the World Health Organization that gave a 60 to 70 percent range of infections and vaccines to reach herd immunity*.

PCCI’s forecast and estimates have been developed in coordination with and reviewed by community health leaders in Dallas County including experts at UT Southwestern Medical Center, Dallas County Health and Human Services and Parkland Health & Hospital System.

“Our predictions for Dallas County to reach its herd immunity tipping point include algorithms to predict total infections and forecasts of vaccination rates. We encourage the community to participate in virological studies such as the one conducted by our colleagues at UT Southwestern (https://utswmed.org/covidstudy/) so we can better understand the community infections and impact. We also need to register and vaccinate the most vulnerable as well as the rest of the population as soon as they are eligible,” said George ‘Holt’ Oliver, MD, PhD, Vice President of Clinical Informatics at PCCI.

PCCI will update its forecast monthly to understand how well the county is progressing toward its 80 percent vaccinated and infected and recovered rate. The updates will incorporate the latest data, intelligence and information from new studies, research and developments regarding the COVID-19 pandemic and impact of emerging strains.

PCCI has made available an important tool to help Dallas County residents stay vigilant and understand their personal risk, the MyPCI App, a free wed-base app that will help individuals make informed choices by providing an on-demand, location-based personal risk assessment of possible COVID-19 exposure. MyPCI is a sophisticated machine learning algorithm, geomapping and hot-spotting technology that uses daily updated data from Dallas County Health and Human Services (DCHHS) on confirmed positive COVID-19 cases and the population density in a given neighborhood. Based on density and distances to those nearby who are infected, the MyPCI App generates a dynamic personal risk score.

To use the MyPCI App, go to, https://pcci1.wpengine.com/mypci/, click on the link and register (Using code: GP-7xI6QT). Registration includes a request for individual location information that will be used only for generating a risk assessment, never shared. Once registered, simply login daily and a COVID-19 personal risk level score will be provided along with information to help individuals make informed decisions about how to manage their risk.

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 Non Medical Drivers of Health to address the needs of vulnerable populations.

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*New York Times, Dec. 24, 2020: “How Much Herd Immunity Is Enough?”
https://www.nytimes.com/2020/12/24/health/herd-immunity-covid-coronavirus.html

In The News: DCEO Healthcare covers the MyPCI App; a tool that gives you your COVID risk

 

Are You Likely to Get COVID-19 in Dallas? There’s an App for That.

By Will Maddox
Dallas County residents can now get an instant reading of their vulnerability to COVID-19 using an app developed by the Parkland Center for Clinical Innovation. The new technology provides a live, location-specific risk assessment with a score to reflect how vulnerable a person is to the virus.
https://www.dmagazine.com/healthcare-business/2021/02/are-you-likely-to-get-covid-19-in-dallas-theres-an-app-for-that/

January COVID-19 Vulnerability Index Update: Risks Intensifying to Highest Levels of The Pandemic

DALLAS – The post-Christmas and New Year’s holidays contributed to soaring risk values recorded by PCCI’s COVID-19 Vulnerability Index, beyond any previously recorded levels. However, with the end of the holiday season, PCCI experts are optimistic that January’s extreme spike is the infection’s peak.

“With the major 2020 holidays concluded, over the next several months we can see the return to daily life on the horizon,” said Thomas Roderick, PhD, Senior Director of Data and Applied Sciences at PCCI. “With ongoing vigilance, including continued adhering to local health official guidance, social distancing, face covering, and registering for vaccinations as soon as you’re able, we can anticipate that the recent high case counts are behind us.”

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

While there are signs that the recent peak may be over, January’s Vulnerability Index numbers showed that Dallas County was severely battered by COVID-19, especially in the ZIP codes struggling with socioeconomic issues. For example, the ZIP code 75211, around Cockrell Hill, continues to top the most at-risk area in Dallas, as it has since the Vulnerability Index began recording data in June. However, in January, 75211, the area exceeded the record value that it set in December, increasing its vulnerability value by 38.9 points. The ZIP code 75243 holds the position as the second most vulnerable area in Dallas County with a vulnerability value of 129.99.

“The ZIP codes, 75211 and 75243 are two areas of Dallas County facing the highest socioeconomic challenges; the fact that they are the most identified as highly vulnerable to COVID-19 shows how the PCCI Vulnerability Index is helping shine the

light on where the help is needed most,” said Dr. Roderick. “The entire healthcare community in Dallas County is striving to equitably mitigate the spread of COVID-19, and the Vulnerability Index offers factual data to support that effort.”

Other ZIP codes with major leaps in their vulnerability values include 75217, 75204 and 75040. The top-most vulnerable ZIP codes averaged a vulnerability value of 100.53 in January compared to the top-most in December that averaged a vulnerability value of 79.77, underscoring the rise in cases from mid-December 2020 to mid-January 2020.

PCCI recently launched the MyPCI App, another program to help inform the residents of Dallas County to their individual risks. The MyPCI App, free to register and use, is a secure, cloud-based tool that doesn’t require personal health information and doesn’t track an individual’s mobile phone data. Instead, it is a sophisticated machine learning algorithm, geomapping and hot-spotting technology that uses daily updated data from the Dallas County Health and Human Services (DCHHS) on confirmed positive COVID-19 cases and the population density in a given neighborhood. Based on density and distances to those nearby who are infected, the MyPCI App generates a dynamic personal risk score.

To use the MyPCI App, go to, https://pcci1.wpengine.com/mypci/, click on the link and register (Using code: GP-7xI6QT). Registration includes a request for individual location information that will be used only for generating a risk assessment, never shared. Once registered, simply login daily and a COVID-19 personal risk level score will be provided along with information to help individuals make informed decisions about how to manage their risk.

“We have seen that proximity is one of the most important factors in pandemic management and personal protection,” said Dr. Roderick. “While we wait for vaccine programs to take hold, we can use the MyPCI App to control our own risk of exposure and help bend the curve.”

 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 Non Medical Drivers 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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