We are constantly challenging ourselves to incorporate new ideas that improve the way we work and our work outcomes.
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.
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.
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
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.
Our sister company, Pieces Technology, Inc. has commercialized Pieces Iris®, a scalable, cloud-based case management platform that can help organizations better address the social, economic, and behavioral determinants of health. www.piecestech.com