Our Impact

    Our vision and mission are clearly defined and powers our efforts to make real and substantial impact on the health of our community

    From our powerful data-driven applications contributing to the regional pandemic response, to using AI to predict trauma mortality in the emergency department, to reducing avoidable asthma-related ED visits and hospitalizations through data science and community outreach, we’ve been successful in putting data to work to improve health.

    For example, PCCI has a number of programs that have had substantial impact on the community and will continue into the furute. For example:Pediatric Asthma

    Along with COVID, PCCI, in collaboration with Parkland Health, has led a highly effective fight against pediatric asthma. Starting in 2015, Parkland Community Health Plan (PCHP) and PCCI launched a unique Pediatric Asthma Quality Improvement program utilizing a real-time analytic solution that proactively― and dynamically― identifies very high-, high-, and medium-risk asthma patients for targeted, direct decision support interventions. The team evaluate and update the solution every year to both improve its accuracy and to enhance actionable insights that guide point-of care interventions. The ultimate goals are to reduce unnecessary hospital utilization and cost, increase patient adherence to medication and preventive office visits and improve overall health care experience. Moreover, the team used the risk solution to directly engage higher-risk patients into a text-messaging program for patient education and medication reminders. Here are current results:

    • ~93,000 unique children with asthma risk-stratified to-date across both initiatives (PCHP and CHNA)

    • Over 22,000 children with asthma risk-stratified every month and ~45,000 every year, with a rapidly increasing impact

    • Over ~1800 high-risk children with asthma impacted by the text-messaging program

    IMPACTFUL RESULTS
    • 30 – 40 percent reduction in asthma-related ED visits
    • 50 percent reduction in asthma-related inpatient admissions
    • 32 – 50 percent increase in providers prescription of asthma controller medications

    IMPACTFUL SAVINGS
    • 50 percent drop in annual total asthma cost to PCHP
    • Approx. $30 million saved as a result of the risk-driven, multi-stakeholder pediatric asthma framework
    • The text-messaging program has yielded an additional 6-fold drop in asthma-related ED visits among participants vs. non-participants
    • Over 85% of participants remain in the text-messaging program for more than 12 months and >90% feel empowered to care for asthma as a result of the program

    Preterm Birth Prevention:
    To better serve pregnant women in our community, PCCI and PCHP developed and implemented an innovative Preterm Birth (PTB) Prevention program that uses a machine learning algorithm, healthcare data, and SDOH to identify pregnant women who are at a higher risk of PTB. The program engages these women through text messages designed to help them be proactive in seeking care during pregnancy.

    The program has been running successfully for more than four years in seven counties in North Texas and has:

    • Risk stratifies about 13,000 pregnant women per year

    • Reduced preterm birth rates by 20
    • Increased prenatal doctor visits by 8-15 percent

    In a survey of the program participants, 73% of respondents agreed this program made them better prepared to take care of themselves and their babies.

    Building Connected Communities of Care – Dallas AHC Model

    The CMS Accountable Health Communities (AHC) Model focuses on systematically identifying and addressing health-related social needs (HRSN) of eligible individuals. HRSN include housing instability and quality, food insecurity, utility needs, interpersonal violence, and transportation needs (beyond medical transportation). The 5-year program was designed to screen for HRSN and refer and navigate individuals to community-based resources and to collect data to quantify the impact on healthcare costs and utilization. The program operates in 21 states across the country and PCCI serves as one of three AHC model implementation sites in Texas.

    In 2022, the Dallas AHC model successfully completed its fifth (and final) AHC model year while continuing to exceed annual navigation requirements (connecting over 3,000 individuals annually with community resources and providing individual follow-ups for up to 12 months in the fourth year of the model), despite the challenges of the ongoing COVID-19 pandemic. PCCI’s preliminary analysis of Medicaid claims data has provided promising results in relation to reduced ED utilization and cost for beneficiaries engaged in the Dallas AHC model.

    When comparing claims data for over 5,000 individuals 12 months prior to engagement with AHC, and 12 months post navigation services, PCCI saw a reduction in average ED utilization of 48%, a reduction in average inpatient admissions of 25%, and a reduction in average total costs of $7,000 per beneficiary paid by Medicaid. While it is too early to draw any definitive conclusion (we plan to conduct more advanced analysis later in Year 5), these early results are extremely promising.