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Application to establish Accountable Health Communities in Dallas County - Track 3

Award Number: 1P1CMS331580
ORGANIZATION: HEALTH CARE FINANCING ADMINISTRATION, OFFICE OF ACQUISITION AND GRANTS
OPDIV: CMS
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: DEMONSTRATION
PERIOD OF PERFORMANCE START DATE: 05/01/2017
PERIOD OF PERFORMANCE END DATE: 04/30/2022

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Application to establish Accountable Health Communities in Dallas County - Track 3 - Project AbstractIt is increasingly recognized that healthcare utilization and key clinical outcomes are susceptible to social determinants of health. In Dallas County, there has been significant effort by major stakeholders to address health-related social needs through novel approaches. The Dallas Information Exchange Portal (Dallas IEP) project, led by the Parkland Center for Clinic Innovation (PCCI), a 501 (c) (3) organization affiliated with Parkland Health & Hospital System, has been the underlying infrastructure for this effort. The Dallas IEP project has created a technology platform (Pieces IrisTM and Pieces PlexusTM), the community alliances, the governance structure and the political will for cross-sector data sharing, care coordination, and community alignment to resolve the health-related social needs of patients treated at local health systems. This enormous prior work in Dallas creates an ideal environment to implement Track 3 of the Accountable Health Communities (AHC) program designed by the Centers for Medicare and Medicaid Innovation Center (CMMI). The Dallas AHC Program goals are to further leverage the Dallas IEP work to: 1) design and implement a uniform system of systematic screening, referral, and navigation for health-related social needs among Medicare and Medicaid beneficiaries; 2) achieve seamless care coordination and data sharing among healthcare providers and community service providers; and 3) positively impact population health and cost of care outcomes in Dallas. PCCI, who will serve as the bridge organization, has established an enthusiastic consortium including the Texas Medicaid Agency, five of the largest and most influential healthcare systems representing 1.57 million patient visits annually, 289 community service providers including two major umbrella organizations, and a mix of Medicaid HMO and private payers. Twenty-two zip codes with the highest concentration of unmet health-related social needs wit hin Dallas County have been selected for the Dallas AHC program. They have a combined population of more than 600,000, which includes more than 180,000 community-dwelling Medicare and Medicaid beneficiaries, of whom 96,000 (more than 51%) sought care at one of the clinical delivery sites over the past 12 months. Clinical delivery sites (CDS) will use the Dallas IEP technology, integrated with their EHR, to screen patients for five core and two supplemental health-related social needs, refer them to community service providers, and provide navigation to resolve the social needs of high risk patients. The community service providers will receive the referrals through the Dallas IEP platform and document their interventions on the platform without interruption to their workflow. The interoperability of the system will allow both provider types to close the loop on patient referrals and outcomes. PCCI will convene a community advisory board to address gaps between community needs and available resources, and propose a sustainability model. As a result of the Dallas AHC, CDS participation in cross-sector coordination will increase by 80%.The Dallas AHC program is requesting a total of $4,509,913 over five years, of which $1,200,000 will be used to fund patient screening and navigation activities at clinical delivery sites, $395,000 for technology implementation and data sharing, $69,000 for community alignment, $2,501,830.14 for program administration, and the remaining for start-up and indirect costs. The deep breadth of support, prior work, and enthusiasm for the Dallas AHC program positions us for successful implementation and long-term sustainability beyond the 5-year grant period.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2022 ( Subtotal = $0 )
2022	2021	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	5	9/12/2022	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2022	2020	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	5	9/12/2022	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2022	2019	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	5	9/12/2022	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2022	2018	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	5	9/12/2022	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2022	2017	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	5	9/12/2022	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $0

Issue Date FY: 2021 ( Subtotal = $940,435 )
2021	2021	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	00	5	4/28/2021	NON-COMPETING CONTINUATION	$940,435
														Subtotal = $940,435

Issue Date FY: 2020 ( Subtotal = $935,813 )
2020	2020	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	00	4	4/30/2020	NON-COMPETING CONTINUATION	$935,813
2020	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	05	3	10/22/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $935,813

Issue Date FY: 2019 ( Subtotal = $924,873 )
2019	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	02	3	7/19/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2019	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	00	3	4/29/2019	NON-COMPETING CONTINUATION	$924,873
2019	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	04	3	9/18/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2019	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	03	3	8/16/2019	SUPPLEMENT FOR EXPANSION	$0
2019	2019	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	3	5/14/2019	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2019	2018	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	03	2	4/3/2019	SUPPLEMENT FOR EXPANSION	$0
														Subtotal = $924,873

Issue Date FY: 2018 ( Subtotal = $908,231 )
2018	2018	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	02	2	9/12/2018	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
2018	2018	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	01	2	8/27/2018	SUPPLEMENT FOR EXPANSION	$0
2018	2018	Parkland Center For Clinical Innovation	8435 N Stemmons Fwy Ste 1150	Dallas	TX	75247	DALLAS	USA	Accountable Health Communities	00	2	5/3/2018	NON-COMPETING CONTINUATION	$908,231
2018	2017	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N Stemmons Fwy Ste 1150	DALLAS	TX	75247	DALLAS	USA	Accountable Health Communities	01	1	1/8/2018	ADMINISTRATIVE SUPPLEMENT ( + OR - ) (DISCRETIONARY OR BLOCK AWARDS)	$0
														Subtotal = $908,231

Issue Date FY: 2017 ( Subtotal = $800,648 )
2017	2017	PARKLAND CENTER FOR CLINICAL INNOVATION	8435 N STEMMONS FWY STE 1150	DALLAS	TX	75247	DALLAS	USA	Accountable Health Communities	00	1	4/5/2017	NEW	$800,648
														Subtotal = $800,648

Grand Total All Awards = $4,510,000

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Application to establish Accountable Health Communities in Dallas County - Track 3

Award Number: 1P1CMS331580

ORGANIZATION: HEALTH CARE FINANCING ADMINISTRATION, OFFICE OF ACQUISITION AND GRANTS

OPDIV: CMS

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: DEMONSTRATION

PERIOD OF PERFORMANCE START DATE: 05/01/2017

PERIOD OF PERFORMANCE END DATE: 04/30/2022

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