Wednesday, April 30, 2025
4/30/2025
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.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).