PCCI: Supporting Vulnerable Communities
PCCI started as a department within Parkland Health and was spun out as an independent, not-for-profit organization in 2012 to not only serve the needs of Parkland, but to also pursue additional transformative initiatives that could have a broader impact. PCCI remains tightly connected to Parkland, the Parkland Foundation and the Parkland Community Health Plan. The organization’s collaborative work focuses on the needs of vulnerable populations across North Texas and beyond.
PCCI’s teams of acclaimed clinicians and expert data scientists strive to accomplish its mission of advancing the health of underserved and vulnerable communities through multiple approaches that produce a significant impact. PCCI believes that data, done right, has the power to galvanize communities, inform leaders and empower people. It also believes that clinical data only paints a partial picture of an individual and his or her specific needs. The organization’s business model focuses on cutting edge uses of data science, social determinants of health and clinical expertise across clinical and community settings.
PCCI collaborates with philanthropic foundations, federal agencies, rural and urban health systems, payers, local municipalities, community-based organizations and others who share PCCI’s common interest in finding the most impactful ways to address the needs of vulnerable populations.
This past year PCCI continued to advance each facet of its mission of delivering positive impact on the health of the North Texas community. During the pandemic, PCCI was uniquely positioned to support the community with innovative solutions that empowered public health officials and informed the public with science-based data. While COVID received a great deal of focus during the last few years, PCCI continued to utilize its advanced analytics and clinical expertise to create innovative approaches to solving other important healthcare issues. PCCI expanded its influence beyond North Texas with several new multiyear contracts and partnerships, including University Health System in San Antonio, Episcopal Health Foundation and six cross-Texas rural communities, and a multi-hospital and community coalition led by the Dell Foundation in Austin. Nationally, PCCI is a member of the inaugural Health AI Partnership alongside Duke, Mayo, Berkeley, Yale and a few other renowned national leaders in Artificial Intelligence and Machine Learning.
Additional programs and innovations PCCI has led:
Along with COVID, PCCI, in collaboration with Parkland Health, has led a highly effective fight against pediatric asthma. Starting in 2015, Parkland CommunityHealth 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.
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.
Building Connected Communities of Care – Dallas AHC Model
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.