VIDEO: PCCI Unveils Community Vulnerability Compass, Giving Deep Insights Into the Health of Texas Communities
PCCI’s CEO, Steve Miff, PhD, and Chief Funding and Innovation Officer, Leslie Wainwright, PhD, reveal the details of PCCI’s newest innovation, the PCCI Community Vulnerability Compass. The CVC can help virtually any Texas-based organization (hospital system/health plan, care provider, CBO, public health entity, philanthropic funder, etc.) seeking to understand not only where its community’s most vulnerable residents live but also many of the underlying, multi-dimensional root cause factors driving these residents’ poor health and healthcare access and ability to thrive. Through a fuller understanding of these root causes, organizations can develop better programs, resources, and interventions to eliminate disparities, achieve health equity, and improve the health and well-being of vulnerable residents.
Click on the link below to view the video on PCCI’s LinkedIn page:
PCCI’s Community Vulnerability Compass Shows Mental Health Vulnerability Highest In Economically Challenged Areas of Dallas County
The Parkland Center for Clinical Innovation (PCCI) has released an analysis of Dallas County using its cutting-edge Community Vulnerability Compass (CVC) tool that shows how economically disadvantaged areas of Dallas County are also the most vulnerable to mental health concerns.
Sections in the south and southeast areas of Dallas County, which historically have had socio-economic disadvantaged populations, are revealed to have the highest mental health vulnerability rating (“Very High”) by the CVC. The “Very High” designation indicates that these areas are in the top 20 percent of vulnerability, when compared to the rest of Dallas County.
“In addition to poor mental health, these areas also have some of the lowest life expectancies and highest density of chronically ill populations in the County,” said Steve Miff, PhD, CEO and President of PCCI. “Just like our bodies need preventative care to optimize our physical health, our minds need the same attention to improve our mental health. There is also a strong correlation between your environment and both mental and physical health. In fact, these are tightly interwoven, where poor physical health can negatively impact mental health, and poor mental health can adversely impact physical health. We at PCCI believe that efforts to improve health must address the whole person. To lift the health of our community, you can’t focus solely on chronic diseases, but must also concurrently tackle mental health and address life barriers to access resources, especially in the most at-risk neighborhoods.”
The CVC is designed to help Texas-based organizations seeking to understand (at a county, ZIP code, census tract, or block-group level) not only where its community’s most vulnerable residents live but also many of the underlying, multi-dimensional root cause factors driving these residents’ poor mental and physical health and ability to thrive. The CVC tool includes 26 clinical and socio-economic indicators that reveal the health, resiliency, and economic vibrancy of neighborhoods.
PCCI’s CVC measures mental health by analyzing CDC data on the number of adults 18 years and older who stated that their mental health, which includes stress, depression, and problems with emotions, was not good for 14 or more of the last 30 days. The CVC also analyzes economic, education, safety, environmental, and other diverse health and social indicators to create a full picture of the County’s community health, as well as community health across the entire State.
“As a start, these data can be extremely useful for community action groups, charities, or healthcare organizations to target education/information about mental health to these high vulnerability block groups. Although this map only highlights those 18 and older, we know caregivers’ mental health affects the children they are caring for, so organizations can also consider supporting schools in these areas. Sharing resources, teaching people about how to recognize when someone around them is struggling and promoting activities that encourage improving mental health are things that each of us can do,” said Jacqueline Naeem, MD, Senior Medical Director at PCCI.
Dr. Naeem added that the CVC’s analysis includes a wide range of data points, providing a true, holistic picture of who needs the most help and where to find them. The data PCCI provides is based on the best, most currently available information, which serves as a powerful tool to allow for proactive support of those in need.
“There is still stigma that exists around mental health, and mental illness that we need to work together to overcome,” said Dr. Naeem. “This data allows us to focus on the whole person by concurrently addressing the physical and mental needs of our neighbors and identifying their local barriers to access services. In doing so, the location and type of services can be tailored in ways that are more convenient for the recipients and education can be hyper-localized and tailored to those recipients in a more culturally empowered way.”
Parkland Center for Clinical Innovation (PCCI), founded in 2012, is celebrating a decade as a not-for-profit, healthcare innovation organization affiliated with Parkland Health. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations.
This Spring, HIMSS (Healthcare Information and Management Systems Society), a global thought leader and member-based society committed to reforming the global health ecosystem with information and technology, offered several platforms for PCCI’s experts to share their innovative programs with thousands of healthcare IT professionals.
PCCI in collaboration with leaders from Parkland Health, Parkland Community Health Plan and Dallas County, have delivered eight presentations, four at the national HIMSS conference in Chicago and four at the Texas HIMSS regional conference in Dallas. These eight presentations highlight the impactful and diverse applications of artificial intelligence and social determinants of health in clinical and populations health programs.
These presentations include:
HIMSS Annual National Convention:
“ML-AI-Driven Community Coalition, Digital Outreach Improves Asthma Among Low-Income Children”
Teresita Oaks, MPH, Director of Community Health Programs, Parkland Health
Description: PCCI partnered with Parkland Health to develop a Machine Learning/Artificial Intelligence asthma risk prediction model, using diverse social and clinical data sources to identify rising risk for asthma-related ED visits/hospitalizations among low-income children with asthma. Monthly risk-reports were leveraged to develop a multidisciplinary coalition across six high-asthma-morbidity Dallas County zip codes, for communitywide interventions.
“Using Data-Driven Insights to Prioritize Programs Addressing Social Vulnerabilities”
Natasha Goburdhun, MS, MPH, Vice President, Connected Communities of Care, PCCI
Paula Turicchi, FACHE, Chief Strategy Officer at Parkland Community Health Plan
Description: Despite the increasing awareness of the importance of social determinants of health (SDoH) and their influence on health outcomes, few organizations have adequate, contextualized insights to better address interrelated, social needs across a community. This presentation demonstrated how the Parkland Community Health Plan leveraged a three-tiered strategic analysis of SDoH and patient-level data to identify and prioritize programs to meet their members’ social needs.
“Integrating Universal Suicide Screening in EMR Improving Detection of Risk”
Jacqueline Naeem, MD, Senior Medical Director/Program Director AHC, PCCI
Kim Roaten, PhD., UT Southwestern Medical Center
Description:
In 2015, a universal suicide screening program was implemented at Parkland Health in which all patients 10 and older are screened for suicide risk during every provider encounter. Analysis was completed on over 3 million unique patients to understand the distribution of levels of risk in the population, as well as insights around the impact of the pandemic on patients identified with suicidal ideation.
“Patient Segmentation and Clustering Using ML to Develop Holistic, Patient Programs and Treatment Plans”
Yusuf Tamer, PhD, Senior Data and Applied Scientist, PCCI
Albert Karam, MS, MBA, Vice President, Data Strategy Analytics, PCCI
Brett Moran, MD, Chief Medical Informatics Officer, Parkland Health
Description:
In close collaboration with Parkland, PCCI developed a novel, advanced analytics process called Know-Thy-Patient (KTP) to group patients other than by their primary disease or diagnoses (e.g., diabetes, hypertension). By integrating and analyzing metrics associated with barriers to health care access — social vulnerabilities, transportation barriers, lack of insurance coverage — into the clinical context, health strategies adopting these cohort-similarity approaches can more readily incorporate a wider variety of patient-centered, whole-person approaches to care, such as integrated practice units, targeted digital programs, virtual and in-person support groups, and focused outreach and communication.
HIMSS Texas Regional Conference
“AI-Driven Interventions Improve Preterm-Birth Among Medicaid Pregnant Members” PCCI’s Yolande Pengetnze, MD, VP Clinical Leadership joins Amrita Waingankar, MD, MBA, Senior Medical Director at Parkland Community Health Plan to share how they successfully implemented preterm birth prevention program in Dallas.
“Predicting Mortality of Trauma Patients” PCCI’s Albert Karam, Vice President of Data Strategy and Analytics presents with Parkland’s Adam J. Starr, MD, will discuss this innovative predictive trauma model.
“Data Driven Approach to Addressing Health Related Social Needs (HRSN)” PCCI’s Jacqueline Naeem, MD, Medical Director will present with Vidya Ayyr, MPH, CHW, Director Social Impact at Parkland about the Accountable Health Community model recently and successfully completed in Dallas.
“Implementing Inpatient Sepsis Early Prediction Model” PCCI’s Yusuf Talha Tamer, PhD, Principal Data and Applied Scientist, will present with Parkland’s Nainesh Shah, Hospital Physician, DMIO, will share how their predictive sepsis model is changing how sepsis can be addressed.
By Yolande Pengetnze, MD, MS, FAAP, Vice President of Clinical Leadership, PCCI
Recently, the March of Dimes (MOD) released its report card (https://www.marchofdimes.org/peristats/reports/united-states/report-card) that highlights the latest key indicators describing the state of the nation’s maternal and infant health. The MOD gave the U.S. a near failing, D+ grade for its 10.5 percent preterm birthrate.
The rising U.S. preterm birth rate is partly explained by racial/ethnic disparities, with Black women having ~50% higher risk of preterm birth than White women. The single most important intervention to prevent preterm births is adequate prenatal care. Yet one in 5 pregnant Black women and 1 in 4 pregnant American Indian/Alaska Native women do not receive adequate prenatal care.
The high U.S. preterm birth rate, while concerning, can be reduced by closing racial/ethnic and socioeconomic gaps in care through programs that increase access to prenatal care and address non-medical determinants of health (NMDOH, also known as Social Determinants of Health or SDoH). Moreover, widening racial/ethnic disparities in maternal death are partially explained by the same factors that drive preterm birth risk. Therefore, addressing preterm birth risk in a holistic manner has the added benefit of potentially (and positively) impacting maternal mortality.
At PCCI, we’ve developed ways to identify and support at-risk pregnant women in bringing their pregnancies to term. Specifically, to better serve pregnant women in our community, PCCI, the Parkland Community Health Plan (PCHP) and Parkland Health developed and implemented, beginning in 2018, a novel preterm birth prevention program that uses a machine learning algorithm, healthcare data, and SDoH to identify pregnant women who are at a higher risk of pre-term birth. The program engages these women through text messages designed to help them better manage their health and proactively seek care during pregnancy.
Our program consistently risk stratifies about 13,000 pregnant women per year by combining clinical, socioeconomic, and demographic indicators from diverse data sources to predict pregnant women who present a high risk for preterm delivery. By predicting preterm birth accurately and in a timely manner, we are able to target patient education and engagement, as well as clinical and population-level interventions to reduce preterm birth rates among low-income Medicaid patients.
As socioeconomic factors and psychosocial stress are increasingly recognized as important drivers of preterm birth risk, PCCI’s risk prediction model paves the way for novel approaches to preterm birth prevention, combining clinical and non-traditional preterm birth prevention interventions addressing NMDOH targeted to high-risk patients.
This ongoing program enables early interventions, including enrolling women in a text education and reminder program that has helped reduce preterm birth rates by 20 percent and has increased prenatal doctor visits by 8-15 percent.
The combination of technology― a predictive model that identifies the most at risk and a risk-driven text messaging program―efficiently reaches expectant mothers where they are in their pregnancy journey. Rather than simply throwing out a broad net for all pregnant women, through our examination of NMDOH elements, we gain a clearer picture of who we need to help and why. This makes interventions much more holistic, effective, and cost efficient.
Through trial and error, we found that simple texting was the best way to reach expectant mothers and provide positive and easy-to-understand messages and reminders to help them to reach term. Examples of texts include:
This innovative yet simple approach for participant management allows us to extend great resources and focus on those who need help the most. In fact, in our quarterly surveys of the program participants, an average of 73% of respondents have agreed this program made them better prepared to take care of themselves and their babies. These results are meaningful not just to the mother and her family, but to the entire community.
It is extremely important to emphasize that while the program itself is innovative, it can be scaled and utilized in just about any community. Preterm birth is not an issue that we want to simply shrug our shoulders about. Each time we have a premature birth, the costs to the baby, parents, hospital, and ultimately the community can be enormous. The life of a premature baby can be one of hardship and challenge and create lifelong difficulties for the individual, their family, and the society at large. Our collaborative team behind our preterm birth prevention program passionately believes that any preterm birth that can be prevented is a chance for a life to flourish and make a difference in the world.
About Yolande Pengetnze
Yolande Pengetnze, MD, MS, FAAP, is PCCI’s Vice President of Clinical Leadership where she leads multiple projects including population health quality improvement projects focusing on preterm birth prevention and pediatric asthma at the individual and the population level. Dr. Pengetnze received her MD from the University of Yaounde in Cameroon and completed a Pediatric Residency at Maimonides Medical Center in New York. She was a faculty member at UTSW’s General Pediatric Hospitalist Division where she completed a General Pediatric/Health Services Research Fellowship training and earned a Master of Sciences in Clinical Sciences.
Interactive dashboard spotlights Dallas County communities with high asthma rates
Parkland, PCCI, DCHHS partner to provide insights for child caregivers
DALLAS –Parkland Health and Dallas County Health and Human Services (DCHHS) in collaboration with Parkland Center for Clinical Innovation (PCCI) launched a new Pediatric Asthma Surveillance System (PASS)* that describes community-level information regarding pediatric asthma risk factors in Dallas County.
The interactive dashboard was developed as part of the pediatric asthma initiative through the Dallas County Community Health Needs Assessment. The overall goal of this surveillance system is to provide current and accurate data to stakeholders interested in planning, developing and deploying pediatric asthma interventions, programs and policy; with this in mind, PASS data sets will be updated regularly hereafter.
“The Pediatric Asthma Surveillance System provides valuable key insights into pediatric asthma vulnerability and the associated clinical, demographic, environmental and social/economic drivers. Being able to drill down to neighborhoods and specific census tracts will provide public health leaders and agencies with data they need to address health disparities in the community and improve pediatric asthma for all,” said Steve Miff, PhD, PCCI’s President.
PASS includes a novel, validated Pediatric Asthma Vulnerability Index, that integrates health and social data insights to identify communities where children have higher vulnerability to poor asthma outcomes and highlight areas of health disparities. It can also predict the probability of a community-level asthma-related emergency department (ED) visit or hospitalization within three months, by incorporating the effect of 10 community indicators such as socioeconomic conditions, demographic characteristics, medication use patterns, health services utilization and environmental conditions, on community-level asthma risk.
“We plan on using the data from PASS to help us strategize outreach into the community,” said Cesar Termulo, MD, Pediatrician and Associate Medical Director at Parkland. “There are many children who might not be aware that they have asthma. They might solely be having a chronic cough or shortness of breath with exercise. Thus, it is important to find those pockets of Dallas County that might have a higher vulnerability to asthma attacks and raise awareness in the community to diagnose those children who have unrecognized asthma.”
At every geographic level, a risk-driven, color-coded map is displayed in the center with demographic data included below the map. The Vulnerability Index and all indicators are categorized as Very High, High, Moderate, Low or Very Low Risk based on their impact on Pediatric Asthma Vulnerability in the community. The user can drill down from the Vulnerability Index view to specific indicator views by clicking on specific indicators of interest or navigating to the “Other Indicators” tab. The user can also navigate the map from a ZIP Code view to a Census Tract view to further analyze microgeographic disparities and can select a specific geography of interest for further analysis.
The PASS is also meant to support Parkland and DCHHS efforts in reducing poor health outcomes related to pediatric asthma and will be used to outreach and engage parents or caregivers to participate in Parkland’s pediatric asthma text notification. Parkland’s asthma text message program is an interactive tool designed to help parents manage their child’s asthma. Parents can sign up by texting @asthma to 844-721-0839 (except for message/data rates, the text program is free to eligible patients). To learn more about the asthma text program, visit, www.parklandhealth.org/asthma-in-children.
Programs like these are made possible thanks to generous donors who help support our patients. If you want to support the program you can do so, at Ways to Give – Donate – Parkland Health Foundation (istandforparkland.org).
About Parkland Center for Clinical Innovation
Parkland Center for Clinical Innovation (PCCI), founded in 2012, is a not-for-profit, healthcare innovation organization affiliated with Parkland Health. PCCI leverages clinical expertise, data science and social determinants of health to address the needs of vulnerable populations.
*This work is funded in part by Lyda Hill Philanthropies.
Parkland Center for Clinical Innovation (PCCI) and Parkland Hospital in Dallas developed their own program enrolling at-risk patients in a text reminder program. The program’s main goal is decreasing preterm delivery in at-risk pregnant patients. PCCI determined which patients to enroll by using social determinants of health data.
Text messages varied from reminders to arrive at appointments with a list of questions, to take prenatal vitamins and to place seatbelts over the hips instead of the belly. Text reminders changed as patients progressed through pregnancy with notifications in the third month of pregnancy from informing parents that their baby was the size of a peach, to late-term reminders directing patients to ask their doctor about early signs of labor.
PCCI screened 13,000 women for social determinants of health, hypertension, diabetes and mental health risks. Of the enrolled women, preterm delivery decreased by 20%, prenatal doctor visits increased by 8% and costs decreased by 6%.
Yolande Pengetnze, M.D., a pediatrics specialist and program manager of the preterm prevention program, told Fierce Healthcare that 85% of participants preferred texts when receiving prenatal healthcare advice and 74% said the program made them better prepared for parenthood. “We needed a solution that patients could use with one hand because they have a baby in the other,” Pengetnze said.
“A lot of confusing and conflicting information is communicated on social media and that is where patients are going for advice,” Pengetnze said. “The social fabric has changed and people don’t have the same at-home support as they once did. New parents need all sorts of advice from how to feed their baby to what to ask their doctor.”
A deeper dive into Steve’s position that in order to effectively deploy value-based care and sustain it, we have to focus on health in addition to healthcare.
Identifying the first steps organizations need to take to begin building out healthcare data analytics and social infrastructure, and what the biggest challenges are along that path.
How data can be leveraged for the social determinants of health?
When will organizations move beyond population-level social determinant data and move into personalized referrals?
What excites Steve about the future of healthcare and specifically value-based care?
What is on the horizon at PCCI in this time of change in healthcare?
PCCI currently is seeking candidates for the upcoming term of its Sachs Summer Scholars. Focusing on offering opportunities for women, the PCCI Sachs Summer Scholars is one of North Texas’ most prestigious internship programs as it immerses students in the world of healthcare technology and science.
Whether your abilities are in data science, technology, research, engineering, project management or one of the many other areas of healthcare administration and support, everyone at PCCI works together to fulfill our mission: pioneering new ways to health. By joining PCCI, you become part of a diverse healthcare legacy that’s served our community for more than 10 years.
Primary Purpose
Advance the representation of women in Data Science and Technology to promote practical applications of analytics, computing and data science. Assists with special projects and research including technology and analytics in healthcare, in order to gain business knowledge and research experience.
Minimum Specifications
Education
Must be enrolled in a related Bachelor’s degree program at an accredited university, with a minimum of 30 credit hours OR Be a recent college graduate with a four year degree OR Be a current graduate / doctoral student.
Experience
Worked or currently working on projects related to Natural Language Processing, Artificial Intelligence, Machine Learning, computer vision, image analysis, geocoding, computer science or relevant engineering specializations.
Equivalent Education and/or Experience
May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.
Skills or Special Abilities:
Must be computer literate, with basic knowledge of word processing, spreadsheet, and/or database software.
Excellent problem solving skills; flexible and resourceful to efficiently and effectively meet objectives.
Must be able to demonstrate exceptional critical thinking skills to solve challenging advanced analytics problems and provide solid solutions.
Excellent verbal and written communication skills; ability to write and communicate effectively to diverse audiences; presents and represents varying views and perspectives effectively.
Must be flexible and be able to prioritize and reprioritize projects in line with PCCI leaders to meet deadline and deliverables.
Must demonstrate exceptional abilities for high level comprehension of projects and environment as well as remain extremely detail oriented for tasks and responsibilities.
Must be independent and reliable with the ability to drive initiatives to completion.
A successful history of working collaboratively on research projects and the ability to work productively as either a leader or member in reaching shared objectives.
Knowledge of clinical informatics and health care settings.
Must have strong analytic and computer skills in addition to knowledge of database management and data analysis.
Demonstrate Natural Language Processing, Artificial Intelligence, or Machine Learning skills utilizing any computer software.
Must be able to demonstrate a working knowledge of program evaluation methods, research skills, management information systems, and strategic planning.
Highly familiar with database theory, applications, and management systems.
Must be able to demonstrate a working knowledge of statistical methods & analysis, concepts, practices, and procedures.
Research and development in areas of predictive modeling, data mining & management, and other advanced analytics in the development of business intelligence and technology transfer.
Must have working knowledge in advanced data programming language and statistical analysis software. (be able to program in R, Python, Unitex, Lexigram, STATA, SPSS, or SAS statistical software).
Working knowledge in the following methodologies: risk adjustment, time series analysis, recursive partitioning, quantile regression, boot strapping, instrumental variable analysis, Cox proportional hazard models, dynamic Bayesian and machine learning algorithms, Monte Carlo simulations, or neural networks.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
PCCI has released its 2022 Annual Impact Report virtually. PCCI’s 2022 Annual Impact Report outlines PCCI’s efforts over the past year to help support those most in need in our communities.
The report includes insights into PCCI’s innovations including PCCI’s efforts to fight COVID-19 in Dallas the conclusion of the Accountable Health Communities Model in Dallas County, pediatric asthma mitigation, preterm birth prevention and much more.
About Yolande Pengetnze
“We plan on using the data from PASS to help us strategize outreach into the community,” said Cesar Termulo, MD, Pediatrician and Associate Medical Director at Parkland. “There are many children who might not be aware that they have asthma. They might solely be having a chronic cough or shortness of breath with exercise. Thus, it is important to find those pockets of Dallas County that might have a higher vulnerability to asthma attacks and raise awareness in the community to diagnose those children who have unrecognized asthma.”
PCCI has released its 2022 Annual Impact Report virtually. PCCI’s 2022 Annual Impact Report outlines PCCI’s efforts over the past year to help support those most in need in our communities.