To address social determinants of health, Parkland Center for Clinical Innovation (PCCI) developed an innovative information exchange program that connects case workers and providers in the Dallas area—with impressive results, Jessica Kim Cohen reports for Becker's Hospital Review.
Create the links you need for effective acute/post-acute information exchange
In 2015, PCCI--the research and health IT think tank for Parkland Health & Hospital System—launched the Dallas Information Exchange Portal (Dallas IEP), with funding from W.W. Caruth Jr. Foundation. The portal aims to address social determinants of health by improving care coordination among case workers and health care providers. Specifically, the Dallas IEP is designed to monitor the social service needs of individuals who visit health care providers in the area, Kim Cohen reports.
Steve Miff, president and CEO of PCCI, said of the initiative, "Up to 50 percent of clinical outcomes are driven by social, economic, or environmental factors, and not necessarily related to the direct care the individual received." He added, "That has basically set the stage and created the need for this solution to connect communities, and through that, to drive personalized medicine."
How the Dallas IEP was built
To establish the Dallas IEP, the PCCI team in 2011 worked with sister company Pieces Technologies to create Pieces Iris, a case management system that standardizes patient data on the back-end to allow data exchange among participating organizations. The front-end is customized to the user, which enables each group to focus on its specific area—such as food, housing, or job assistance.
According to Miff, that system "facilitated [the Dallas IEP's] broad adoption." He explained, "It wasn't enough for us to just create connections and provide smart referral, even at no cost. In order for them to adopt this system, they needed something that could run their operations."
The Dallas IEP enrolled its first social services organization, Sharing Life Community Outreach, in 2015. According to Kim Cohen, Sharing Life was able to use the exchange to have more "informed dialogues with … clients," using information regarding their food choices and medication adherence.
Where the Dallas IEP stands now
The Dallas IEP now links "two umbrella organizations": the Metro Dallas Homeless Alliance, which comprises over 30 partner agencies, and the Texas Food Bank, which has 200 partners. Overall, the Dallas IEP holds data on more than 100,000 individuals from about 250,000 encounters.
"It's a huge community with a huge social need," Miff said. "The value becomes exponentially greater when more participants are part of the ecosystem, and we've finally reached that tipping point."
And PCCI has been able to use the IEP to pilot several successful programs, Kim Cohen writes. For instance, PCCI used a predictive risk score that shows how homelessness influences adverse clinical outcomes and then established integrated care management and coordination services to intervene. Since the initiative launched, Parkland Health & Hospital System has seen a 26 percent relative reduction in Medicare beneficiary readmissions.
According to Kim Cohen, PCCI in the future plans to target certain clinical populations to personalize referrals. For instance, the team has identified patients with diabetes and patients with hypertension who lack access to nutritious food and designed workflows that help clinicians direct the patients to local food pantries. PCCI may also consider the geriatric population or individuals with behavioral or substance misuse conditions for similar programs, Miff said.
And Miff is looking beyond the Dallas area as well, Kim Cohen writes. According to Miff, more than 600 other health systems and social services have shown interest in participating in the system. "We can really bring these connections beyond Dallas and make them national, as well," Miff said (Kim Cohen, Becker's Hospital Review, 9/21).
From healthy food access to stable housing: The case for collaboration with community partners
Population health leaders know that health care delivery is incomplete without addressing the social determinants of health. But effective patient management cannot only include tasking care teams with addressing patients' social needs on top of their complex clinical needs.
Instead, providers should also partner with community-based organizations already providing quality non-clinical support for a range of needs, from healthy food access to stable housing, to scale patient management beyond traditional care settings.
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