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In Dallas, Partnering with Social Services on Holistic View of the Patient

September 9, 2014
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Ambitious Information Exchange Portal project to link health systems to community service organization data sources

“As we go forward as a country we will have to be more thoughtful about the community resources for health and how accountable care organizations, for example, are working so that when they send Ms. Smith home, she has a home to go to with electricity and so she does not get readmitted or have a health challenge.”
— Karen DeSalvo, M.D., National Coordinator for Health IT, speaking at the eHealth Initiative 2020 Roadmap Executive Summit in Washington, D.C., on Sept. 4, 2014

I read the transcript of Dr. DeSalvo’s talk to the eHealth Initiative just after getting off the phone with Anand Shah, M.D., vice president of clinical services for the Parkland Center for Clinical Innovation, a nonprofit affiliate of Parkland Health & Hospital System in Dallas. I thought her comments were exactly in tune with what Dr. Shah had just been telling me: that it is time for healthcare providers to take a more holistic view of the lives of their patients and build stronger relationships —and data connections — to community social service agencies.

With a 5-year, $12 million grant from the W.W. Caruth Jr. Foundation at Communities Foundation of Texas, PCCI is starting to build the infrastructure to connect clinical and community-based organizations by creating the Dallas Information Exchange Portal (IEP).

As we talk about improving the value of care and population health, one area that has really been neglected, Shah said, is the integration of social services and community-based organizations that impact lives of patients significantly. “Even though they are providing care that has great impact on patients’ lives and individual health, they’re not traditionally aligned with the healthcare sector, so the fundamental premise of the IEP is to see if we could start to connect these organizations to hospitals and health information exchanges and start building that network,” Shah said. “Then we can start to leverage all of that new data to better allow clinical providers to take care of patients in a more holistic fashion and better allow social service providers also to take a more holistic view of the individual they serve.”

 One of the first things they are working on is a case management tool because some of the organizations they are going to be working with don’t have information systems, explained Shah, executive director of the Dallas IEP and an emergency department physician by training. “They need a low-cost tool to help them upload information and participate. We are going to be implementing that with seven organizations in Dallas over the next six months.”

They are working with food delivery, housing and HIV support networks, as well as human services agencies and one providing chronic care support using a community health worker model.

“The first step is creating these stand-alone systems for the organizations and then in the summer of 2015 we will start exchanging information,” he said.

The need for such a tool became obvious to clinicians at Parkland Hospital, the largest safety net hospital in the Dallas community. “People have not only clinical needs but also a lot of unmet behavioral and social needs,” Shah explained. This additional information will be valuable at the point of discharge or when a patient is leaving an emergency department, or when there is a diagnosis of chronic disease in a primary care office. “Some of that information exists in health information exchanges, so we think this will be complementary. (The North Texas Accountable Healthcare Partnership is a non-profit HIE being developed in the Dallas area. “We don’t mean to replace any of that work. We are looking forward to extend their reach,” Shah said. “We just want to bring additional organizations and their data into the mix.”

The holistic focus on patients’ needs has grown out of work PCCI has done with predictive analytics software to cut readmissions at Parkland. One issue health systems face is appropriately allocating resources toward maximum benefit in a resource-constrained environment and at the same time think about individualizing care, Shah said. The Parkland Intelligent e-Coordination and Evaluation System, or PIECES, system was developed several years ago by PCCI CEO Ruben Amarasingham, M.D., when he was assistant medical director for medical services at Parkland.

Shah said the software is EHR-agnostic. It takes information out and runs it against predictive algorithms and puts it back into the EHR. In one study, their research showed that use of PIECES resulted in a sustained 19 percent reduction in readmissions for all heart failure patients.

“One of the reasons we think we were successful was that we didn't use purely clinical information,” Shah said. “We used demographic information in our risk stratification. We recognized early on that the hospital is in a great position to help patients with certain aspects of their care, such as follow-up appointments and medications. But if we don’t address some of their unmet social needs, they aren’t going to be as effective. That was part of the origin of the Information Exchange Portal: How can we provide more holistic care by understanding that what is driving risk is a combination of clinical and social factors?”

Now Texas Health Resources and University Health System in Texas are both using PIECES to focus on readmissions.

“It can run not only across a number of institutions, but also within an institution it can run across a variety of conditions,” Shah said. “We are in active conversations with a number of hospitals and health systems around the country about deploying these tools.”

We’ll check back with the Dallas IEP next year once the data begins to flow between community service organizations, the regional HIE and providers to see how valuable that exchange of information becomes. This may be a model for other regions to follow.