At HIMSS20 in Orlando on March 10, PCCI’s Senior Medical Director, Yolande M. Pengetnze, MD, will present on how machine-learning and artificial intelligence-driven algorithms guide targeted and tailored educational for high-risk Medicaid children with asthma and Medicaid pregnant women at risk for preterm delivery. Click on the image below for all the details.
Available now is a new book from PCCI: “Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations.” This is practical how-to guide for clinical, community, and government leaders interested in building connected clinical-community services.
The book shows how to facilitate cross-sector care coordination; enable community care partners to better provide targeted services; reduce duplication of services across partnering organizations and help to bridge service gaps in the currently fragmented system.
Published by HIMSS, the book will be available on March 9. Reserve your copy today at: HIMSS publishing: https://lnkd.in/eiB2Jq7 Or Amazon.com: https://lnkd.in/eBKH9h7
PCCI’s text messaging program on asthma and preterm birth prevention was featured as a poster presentation at December’s Institute for Healthcare Improvement (IHI) Scientific Symposium. The poster program titled “A Novel Evidence-Based Approach to Digital Outreach Improves Patient Engagement and Health Outcomes in Two Distinct Cohorts of Medicaid Patients,” was presented by by PCCI’s Senior Medical Director, Yolande Pengetnze, MD. Dr. Pengetnze was joined at IHI by Dr. Barry Lachman, from the Parkland Community Health Plan (PCHP) where they shared the poster that demonstrated how PCCI and PCHP support at-risk populations by helping to reduce the harm caused by asthma and preterm births.
Click on the image below to view the entire poster:
What is the future of SDOH? Patient Engagement HIT talks with PCCI CEO Steve Miff about what is on the horizon for implementing SDOH. Click the image below to see the entire story:
By Natasha Goburdhun, MS, MPH, PCCI’s Vice President, Connected Communities 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 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.
From my experience working with the full channel of care, 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.
Scale your initial interventions to other populations, and/or move to more complex social needs.
SPOTLIGHT ON PATIENT CARE:
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 Natasha Goburdhun
As Vice President, Connected Communities of Care, Goburdhun uses PCCI’s advanced analytics to provide detailed insights on community health and social needs and assists community organizations, payers and providers in developing strategies and impact/equity measures that address the needs of vulnerable populations. She has over 20 years of strategic planning and operations experience in health plan, provider and community-based organization sectors.
[1] https://www.solutionreach.com/blog/which-wins-the-national-average-no-show-rate-or-yours
[2] https://patientengagementhit.com/news/overcoming-transportation-barriers-to-drive-patient-care-access
[3] https://patientengagementhit.com/news/do-rideshare-tools-reduce-transport-barriers-patient-no-shows
[4] Healthcare Plays Vital Role in Reducing Recidivism; EthicsDaily.com; November 2, 2017; https://ethicsdaily.com/report-healthcare-plays-vital-role-in-reducing-recidivism-cms-24443/; accessed July 14, 2019.
[5] https://khn.org/news/finding-homeless-patients-a-place-to-heal/
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Patient Engagement HIT included PCCI in a story about 2020 health trends. Click on the image below to read the whole story:
PCCI’s Dr. Manjula Julka, vice president, clinical innovation, was interviewed by Healthcare IT News about how PCCI and Parkland have saved lives with its in-hospital adverse drug event prevention program. Click the image below to read the full article:
Health It Analytics interviewed Steve Miff regarding his views on social determinants of health. Click on the image below to see the whole story:
The Big Unlock Podcast, hosted by Paddy Padmanabhan, features an interview with PCCI CEO Steve Miff. In this episode, Steve Miff discusses how PCCI has developed advanced machine learning algorithms to understand the role of social determinants of health in vulnerable and under-served communities. Click on the image below to hear the podcast.
