Parkland Center for Clinical Innovation - Connected Communities of Care

Connected Communities of Care

Effectively managing health requires a stronger emphasis on non-medical aspects of a person’s life

Connected Communities of Care – The Next Frontier in Healthcare Innovation

A fundamental question facing the healthcare industry is: How do we comprehensively address the needs of patients when those needs extend beyond the boundaries of traditional clinical care?  While there has been much talk about social determinants of health (SDOH), the majority of American health systems don’t yet effectively leverage social, environmental, and economic information when designing population health programs, developing patient-specific treatment plans, locating new services, or conducting Community Health Needs Assessments (CHNA). This needs to change, since data suggests that ~80-90% of health outcomes can be attributed to factors beyond direct medical intervention.


Connected Communities of Care [or CCC] is a SDOH-based framework designed by PCCI to describe a local ecosystem comprised of health systems, payors, community-based organizations (CBO), philanthropic organizations, and local municipality officials to coordinate services that span the clinical-to-non-clinical continuum.  The aim of a CCC is to improve the health, safety, and well-being of a community’s most vulnerable residents and to do this in a coordinated, cost effective, and sustainable manner.

Our Advisory Services:

Building a Connected Community of Care requires a systematic and structured approach with specific goals hinging on the local maturity of community relationships, IT infrastructure, and data sharing agreements. Our approach leverages work pioneered by PCCI as leaders in the field of building and sustaining Connected Communities of Care.

PCCI’s Book: Building Connected Communities of Care

PCCI is dedicated to supporting health systems who are ready to advance their SDOH strategy.  We engage health system innovation and strategy executives, population health leaders, and clinical champions from health systems of all shapes and sizes.

We offer an initial readiness assessment that evaluates multiple organization-specific and market factors to inform how an organization should begin.  We also engage organizations in more comprehensive engagements to go beyond assessing readiness to develop a CCC strategy, operational plan, and implementation roadmap.

CCC Readiness Assessments

Readiness Assessments achieve the following three objectives:

  • Uncover the medical and social needs of a geographic community by leveraging PCCI’s AI/ML predictive modeling
  • Evaluate provider and CBO readiness to design and implement a CCC
  • Capture relevant market dynamics to navigate in order to make a CCC successful

Key findings include, but are not limited to, the following:

  • Identify characteristics of the population that would most benefit from a CCC such as those with behavioral or substance use disorders, low income, multiple chronic conditions, uninsured or underinsured, as well as those receiving services at behavioral health clinics and social service settings
  • Identify social or economic barriers that impact health outcomes such as inability to pay and lacking transportation, social support, employment and insight into health problems
  • Identify specific hot spots where needs appear to be greatest
  • Identify the technical capability, size and setting, and population served by CBOs

CCC Consulting Engagements

CCC Consulting Engagements provide organizations with a customized strategy, operational roadmap and implementation plan based on findings from the readiness assessment.  Engagements follow the CCC framework described in the CCC Playbook and segment work into six pre-defined tracks of activity that range from governance model selection to launching technology-supported clinical and CBO-based workflows.

CCC Consulting Engagements achieve the following objectives, but are not limited to, the following:

  • Finalize CCC goals and desired outcomes
  • Create formal governance structures, policies and operational plans
  • Select and pilot technology platform partner
  • Develop and refine of workflows at clinical and partner sites
  • Craft a sustainability plan, including the design of evaluation measures and an evaluation plan

Click HERE to contact us about supporting your CCC objectives.