Patient Engagement
SUCCESSFUL PARTNERSHIPS
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PCCI remains committed to operational excellence and ensuring that we are continuously striving to improve as an organization both in the foreground and the background of everything we do. We are constantly challenging ourselves to incorporate new ideas that improve the way we work and our work outcomes.

W.W. Caruth, Jr. Foundation at Communities Foundation of Texas

As a nation, we are realizing the fundamental role that social determinants play in an individual’s health and well-being. While we are gaining greater knowledge of the importance of social needs (e.g., food, housing, transportation, and personal safety) to an individual’s health and well-being, the healthcare sector has faced a number of barriers in successfully addressing these upstream factors as they relate to morbidity and mortality of vulnerable populations. Historically, healthcare providers (i.e., hospitals and clinical practices) have struggled to seamlessly and effectively work with those Community-Based (social service) Organizations (CBOs) that help many (especially vulnerable or underserved) community residents address these social needs.

These facts were not lost on the Communities Foundation of Texas (CFT), a large, forward-thinking philanthropic organization based in Dallas, Texas. Leaders from CFT reasoned that if healthcare providers, particularly Parkland, had the ability to work in a more cooperative and coordinated way with local CBOs, then the health and well-being of those at-risk community residents might be enhanced through a holistic approach to their care.
With this vision as a starting point, in 2012 the W.W. Caruth, Jr. Foundation at Communities Foundation of Texas awarded PCCI a groundbreaking grant, through the Parkland Foundation, enabling PCCI to build and launch in 2014 the Dallas Information Exchange Portal (IEP), linking Dallas Fort Worth (DFW) healthcare providers with CBOs to serve vulnerable individuals through the sharing of data and information in the form of a referral and case-management system. The IEP was among the first cloud-based, case-management software applications to be built at scale to connect―in a seamless and efficient manner―healthcare providers and CBOs and the vulnerable community residents they serve. The IEP not only serves as a referral mechanism, allowing providers to send patients presenting in the ER with both medical issues and social needs (e.g., in need of food or shelter) to CBOs (e.g., local food pantries or homeless shelters), it allows the collection of vast amounts of non-PHI demographic and health data on the individuals making up these populations. With the patient’s and network participant’s consent, this information is made available to all entities that the individual comes in contact with in the network to better (and more holistically) understand and manage the patient’s care. The Dallas IEP has represented a quantum leap forward in understanding the makeup of vulnerable populations and begin the work to reduce the impact that SDOH have on vulnerable, underserved populations.

In 2017, as a result of the inclusion of additional CBOs and other diverse social-service entities and providers, PCCI renamed the IEP, Connected Communities of Care (CCC), to recognize its community-wide focus.

Lyda Hill Foundation

INTELLIGENT TECHNOLOGY DEPLOYMENTS FOR THE NEW PARKLAND CAMPUS

In 2015, the Lyda Hill Foundation awarded PCCI, through the Parkland Foundation, a transformative grant “towards the development of technology in the new Parkland Hospital” to further advance patient safety and quality as part of the I Stand for Parkland capital campaign. As one of the country’s largest and most progressive safety-net hospitals, Parkland is required to constantly reexamine—within the ever-evolving healthcare landscape—how it can deliver healthcare more effectively and efficiently in order to ensure access to care for those residents who need it most. Through the work supported by Lyda Hill, PCCI has created and implemented—with Parkland— technology solutions that have not only positively impacted to date nearly 2 million patients but also serve as the building blocks for future research and innovations that will continue to benefit Parkland and the community it serves. For example, as many Parkland patients present in the Emergency Room (ER) with social needs (e.g., food insecurity) in addition to their clinical needs, the work supported by the Grant has positioned Parkland and PCCI to lead the way in developing technology-driven innovations that can further leverage Social Determinants of Health (SDOH) data to better coordinate care and manage the health and well-being of Parkland’s patients.
Through the work under the grant, PCCI developed a wide range of innovative solutions that are a combination of new technologies, predictive models, artificial intelligence (AI) and machine learning (ML), secure platforms, and that incorporate dynamic clinical workflows. All of these solutions were developed and implemented around the core values of accountability, integrity, collaboration, and excellence. In addition, these solutions were designed under Institutional Review Board (IRB) protocol (where appropriate), with several months of rigorous, silent-mode testing for clinical relevance and model-efficacy validation. The following examples of just a few of our solutions represent a combination of new technologies and innovative approaches to connect with patients at the right time in the right setting.

  • EARLY WARNING SYSTEM 2.0 is a real-time predictive model for identifying clinically deteriorating patients in the hospital and can optimize mobilization of resources to act prior to negative outcomes (cardio-pulmonary arrest, respiratory failure, death). This model triggers a page to the Parkland rapid-assessment team for prompt evaluation of the patient and needed interventions.
  • PARADE (Patients at Risk for Adverse Drug Events (ADEs)) is a real-time risk-stratification model that identifies patients who are at high risk for ADEs at the time of hospital admission and could benefit from timely pharmacist intervention.
    SEPSIS SUITE is a group of real-time predictive solutions in the ER and hospital, providing actionable data insights and triggering interventions for patients at risk of sepsis (a deadly syndrome in which 28-50% of cases are fatal). Collectively, these solutions have resulted in observed reduction in mortality and ICU stays.
  • TRAUMA (P-Starr Trauma) is a real-time predictive model of in-hospital mortality assessment of trauma patients for clinical decision support. This model was developed because trauma surgeons needed a dynamic tool to estimate mortality risk for patients so that surgeons could prioritize interventions. The Trauma model is the only known dynamic model that predicts every hour and is integrated in Electronic Health Records (EHR). This innovation was deployed in August 2019 and has the potential to make an enormous impact on the trauma center at Parkland (and beyond) to better patient care, especially in the first 72 hours, when many of the critical-condition patients (from motor-vehicle and other traumatic events) arrive at hospitals with no identification and little or no information about their past medical histories.

Centers for Medicare & Medicaid Services

In 2017, the Center for Medicare and Medicaid Innovation (CMMI) within the U.S. Department of Health & Human Services launched the Accountable Health Communities (AHC) Model demonstration program to determine if helping Medicare and Medicaid beneficiaries identify and address key upstream factors (i.e., health-related social determinants) would reduce inappropriate utilization of Emergency Departments and healthcare expenses. PCCI is one of 30 award recipients, referred to as “bridge organizations,” to oversee the screening of Medicare and Medicaid beneficiaries for social and behavioral issues, such as housing instability, food insecurity, utility needs, interpersonal violence, and transportation limitations, and help them connect with and/or navigate the appropriate community-based services.

Central to this effort was the development by CMMI of a simple Social Determinants of Health (SDOH) assessment screening tool that all demonstration sites (bridge organizations) use to collect information on health-related social needs. PCCI incorporated the needs assessment screening tool into its Connected Communities of Care (CCC) information exchange platform. The CCC allows healthcare providers and CBOs to serve vulnerable individuals through the sharing of data and information in the form of a referral and case-management system linking patients’ clinical needs with their social needs. Through its work in AHC, PCCI has been able to fully document the nature and scope of SDOH needs among Dallas’ most vulnerable population and the role these health-related social determinants play in fostering health and healthcare disparities.

The project described was supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of PCCI and do not necessarily represent the official views of HHS or any of its agencies. For more information about the AHC model, visit https://innovation.cms.gov/initiatives/ahcm

The National Institutes of Health

“Improving CKD Detection and Care in a High Risk and Underserved Population”

The National Institutes of Health generously awarded a collaborative research grant to the University of Texas Southwestern and Parkland Health & Hospital System toward establishing a new model of joint primary care/nephrology care to improve clinical management of risk factors for the progression of chronic kidney disease (CKD) and cardiovascular (CV) complications. This research will also focus on the expansion of disease-specific e-Model development for CKD. We are testing whether the use of Pieces opens in a new window™ will allow earlier detection of patients with CKD, especially among African-American and Hispanic populations, and facilitate earlier CKD care and preparation for renal replacement therapy.

Robert Wood Johnson Foundation (RWJF)

Data Across Sectors for Health (DASH)

In 2016, the Robert Wood Johnson Foundation (RWJF) awarded a $200,000, 18-month grant as part of its Data Across Sectors for Health (DASH) program. In this program, PCCI leverages the Dallas IEP platform to impact the food environment in Dallas by improving the dietary intake and nutritional status of patients who experience food insecurity and have been diagnosed with chronic diseases including diabetes and hypertension. The proposed collaboration, among PCCI, Parkland Health and Hospital System (PHHS) in Dallas, Texas and the North Texas Food Bank (NTFB) and its partner agencies (PAs), would impact not only the food environment, but also increase the coordination of care provided to the target community, and thus potentially improve both the quality of care provided and the self-management of chronic disease. The project would also enhance the already strong and growing ties among healthcare and social services providers in the region and could pave the way for further collaborative opportunities.

W.W. Caruth, Jr. Foundation at Communities Foundation of Texas

The Parkland Information Exchange Portal: Feasibility Study and Design Plan

In 2010, the W.W. Caruth, Jr. Foundation at Communities Foundation of Texas awarded PCCI a visionary grant through Parkland Foundation to conduct a feasibility study and propose a design plan for an information exchange portal that would connect Parkland Health & Hospital System with social service organizations in Dallas in order to facilitate care transitions, improve disease management, and reduce readmissions for Parkland’s most vulnerable patients.

The National Institutes of Health

“Improving Chronic Disease Management with Pieces™”

PCCI and the University of Texas Southwestern Medical Center will implement a collaborative model between primary and subspecialty care in patients with multiple chronic conditions (diabetes mellitus, chronic kidney disease, and hypertension), using the Pieces™ platform. The study will be conducted in partnership with four healthcare systems: Parkland Health & Hospital System (Parkland) in Dallas, TX; ProHealth Physicians Group (ProHealth) in Farmington, CT; Texas Health Resources (Texas Health) in Arlington, TX; and Veterans Affairs North Texas Health Care System (VA) in Dallas, TX.The Pieces™ platform will utilize the electronic medical record (EMR) for data collection, early disease detection, and monitoring and care coordination for patients with chronic medical conditions. The grant builds on a 2011 NIH grant-funded project, “Improving CKD Detection and Care in a High Risk and Underserved Population,” in which Pieces™ identifies patients with CKD and assists in implementing recommended practices at Parkland.This project will be primarily overseen by the National Institute of Diabetes and Digestive and Kidney Diseases and secondarily by the National Heart, Lung, and Blood Institute.

National Center for Advancing Translational Sciences

UT Southwestern Center For Translational Medicine National Center For Advancing Translational Sciences

As part of an NIH sponsored Clinical and Translational Science Award (CTSA), administered through the Center for Translational Medicine at the University of Texas Southwestern Medical Center (UTSW) in Dallas, PCCI will join a team of 62 medical research institutions working collaboratively to improve bench-to-bedside translational care across the country. The vision of UTSW CTSA is to accelerate the translation of new discoveries into clinical practice by integrating and centralizing clinical and translational research (CTR). Dr. Amarasingham, President and CEO of PCCI, will serve as the Director of Biomedical Informatics Program at UTSW, where he will spearhead the informatics effort with a particular focus on predictive modeling using electronic health record data. In addition, PCCI will conduct research to identify social and behavioral risk factors using EHR data as well as participate in innovate inter-institutional research projects and seminars.

The National Center for Advancing Translational Research

“UT-Southwestern Clinical and Translational Alliance for Research (UT-STAR)”

The National Center for Advancing Translational Research of the National Institutes of Health awarded joint grant funding in 2012 to the University of Texas Southwestern to provide the crucial infrastructure necessary for medical scientists to discover and apply new diagnostics and therapeutics for the detection, diagnosis, treatment and prevention of disease. PCCI is providing critical campus-wide informatics support for this grant.

The Agency For Healthcare Research and Quality

UT Southwestern Center of Patient-Centered Outcomes Research (PCOR)

The Agency for Healthcare Research & Quality (AHRQ) awarded joint grant funding to The University of Texas Southwestern Medical Center (UTSW) and PCCI, allowing UTSW to create an integrated Center for patient-centered outcomes research (PCOR) and comparative effectiveness research (CER) at UTSW, Parkland Health and Hospital System (Parkland), Children’s Medical Center (CMC), and the North Texas Veterans Administration Health Systems (Dallas VA). Investigators will harness data in the electronic medical record (EMR) to conduct observational and interventional studies to improve care for high risk, underserved patients and populations. Steve Miff, PhD, PCCI President and CEO, will serve as the Director of the Applied Medical Informatics Cluster for the PCOR Center. PCCI will play a valuable informatics coordination role for PCOR, developing new methods to predict readmissions using data from novel EMR sources previously untested.

United Way of Metropolitan Dallas GroundFloor Program

Pieces Catalyst: PCCI Pilot Payment Model for Integrated Health and Social Service

PCCI is developing Pieces Catalyst, a novel financial model that will realign incentives across social and clinical services sectors to enhance care provision to the Dallas community. Partending with Parkland Health & Hospital System and The Bridge North Texas, a Dallas-based homeless recovery center, this pilot will encourage utilization of existing social resources to holistically address patient health. Pieces Catalyst will revolutionize collaborative care, reinforce capacity building within community organizations, and drive collective community impact.

The Commonwealth Fund

“The Potential of Shared Savings Models to Support Integrated Health and Social Services for Complex Patients”

In addition to a range of clinical services, complex patients also often require social services to address housing, food, and other needs. All of these services need to be well integrated. One way to foster joint accountability for the health outcomes and costs of caring for this population is to establish arrangements between providers and community-based organizations in which the financial savings generated by improvements to efficiency and quality are shared. With grant support from The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy, PCCI will examine existing shared-savings arrangements across health care and other sectors to identify design principles required for success, such as those for calculating savings, setting appropriate savings time frames, and sharing savings among participating organizations. The project findings will set the stage for future implementation and evaluation of shared-savings models in the Dallas–Fort Worth area..

The Commonwealth Fund

“Developing a Clinical Decision Support Tool to Prospectively Identify Patients at High Risk for Hospital Readmission”

The expansion of our congestive heart failure (CHF) readmissions model into an automated all-cause e-Model is generously supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The all-cause model identifies patients at high risk for 30-day readmission within 24 hours of care and subsequent hospitalization, using data collected from 8 hospitals with disparate patient populations.

Gordon & Betty Moore Foundation

“Automating Identification of Patients at a High Risk for Readmission”

The prestigious Gordon and Betty Moore Foundation awarded a grant to PCCI to transform PIECES™ into a robust generalizable and exportable software platform that has new artificial intelligence features.

Gordon & Betty Moore Foundation

“Framework and Action Plan for Predictive Analytics”

The Gordon and Betty Moore Foundation generously awarded a grant to PCCI to form a collaboration of internationally renowned informaticists, health services researchers, statisticians, and legal and ethical experts to identify how the use of real-time healthcare predictive analytics can make the greatest positive impact on patient outcomes and costs. In support of the Foundation’s Patient Care Program strategy, these experts will come together in Washington DC in an action-oriented, outcomes focused meeting designed to create clarity and momentum for healthcare predictive analytics to improve the quality, safety, and cost of healthcare.

The National Cancer Institute

Parkland-UT Southwestern PROSPR Center: Colon Cancer Screening in a Safety-Net

We are grateful to The National Cancer Institute for their grant to the University of Texas Southwestern and Parkland Health & Hospital System for a collaborative endeavor to optimize colon cancer screening through personalized regimens in Parkland’s integrated safety-net clinical provider network. This network serves a large and diverse population of under- and un-insured patients in Dallas County. PCCI is involved in three interlocking studies.

The National Science Foundation

III: Medium: Collaborative Research: Robust Large-Scale Electronic Medical Record Data Mining Framework to Conduct Risk Stratification for Personalized Intervention

The National Science Foundation (NSF) has awarded joint funding to the University of Texas at Arlington, the University of Texas Southwestern Medical Center, Southern Methodist University, and PCCI to design new machine learning algorithms to solve critical challenges for systematically and integratively mining massive electronic medical records (EMR). PCCI is working closely with a team of advanced mathematicians to develop these clinical prediction models using Bayesian modeling approaches. The grant project seeks to develop new computational tools to automate EMR processing and to improve the EMR for prediction of heart failure (HF) readmission providing support for personalized interventions, innovating emerging EMRs applications and facilitating machine learning and data mining techniques.