Building Connected Communities of Care

As a community, aligning efforts across a community to support the safety and well-being of vulnerable and underserved individuals is extraordinarily difficult. These individuals suffer disproportionally from health issues, job loss, a lack of stable housing, high utility costs, substance abuse, and homelessness. In addition to medical care, these individuals often critically need access to community social sector organizations that provide a distinct and complementary set of services, such as housing, food services, emergency utility assistance, and employment assistance. These services are just as vital as healthcare services to these individuals' long-term health and well-being, with data suggesting that 80-90% of health outcomes can be attributed to factors beyond direct medical intervention. This book proposes a novel approach to the coordination of medicine and social services through the use of people, process, and technology, with the goal being to streamline coordination between medical and Community-Based Organizations and to promote true cross-sector patient and client advocacy. The book is based on the experience of Dallas, TX, which was one of the first metropolitan regions to develop a comprehensive foundation for partnership between a community's clinical and social sectors using web-based information exchange. In the 5 years since the initial launch, the authors have been able to provide seamless connection, communication, and coordination between healthcare providers and a wide array of community-based social service organizations (a/k/a Community-Based Organizations or CBOs), criminal justice entities, and various other community organizations, including non-collegiate educational systems. This practical how-to guide is the codification of transferrable lessons from successes and challenges faced when working with clinical, community, and government leaders. By reading this playbook, leaders interested in building (or expanding) connected clinical-community services will learn how to: 1) facilitate cross-sector care coordination; 2) enable community care partners to better provide targeted services to community residents; 3) reduce duplication of services across partnering organizations; and 4) help to bridge service gaps in the currently fragmented system. Implementation of services, as recommended in this book, will ultimately streamline assistance efforts, reduce repeat crises and emergency funding requests, help address disparities of care, and improve the health, safety, and well-being of the most vulnerable community residents.

Dr. Keith Kosel is a Vice President at Parkland Center for Clinical Innovation (PCCI), a leading, non-profit, data science, artificial intelligence and innovation organization affiliated with Parkland Health & Hospital System, one of the country's largest and most progressive safety-net hospitals. At PCCI, Keith is leveraging his passion for - and extensive experience in - patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and underserved populations. Keith earned a PhD in anatomy from the University of Iowa College of Medicine, an MHSA in medical care administration at the University of Michigan School of Public Health, and an MBA in finance from the University of Detroit. Keith taught for twenty-five years at the university and medical school level, most recently focusing on epidemiology and population health. He has authored thirty publications, including multiple book chapters, and co-authored a book on population health. Before joining PCCI, Keith served in various leadership positions at Vizient, Inc., where he designed and led Vizient's national initiatives around population health, established company strategies and large-scale quality improvement programs for hospitals and clinicians related to healthcare reform (i.e., bundled payments, patient safety, and patient engagement), led the company's measurement and analytics group, and as Senior Vice President oversaw Vizient's national office focusing on public policy and legislative advocacy. Before coming to Vizient, Dr. Kosel was Director of Clinical Programs at Blue Cross Blue Shield of Michigan where he built, implemented, and oversaw disease-management and care-management programs for BCBSM's three largest customers - Ford, General Motors, and Fiat Chrysler. Keith lives in the Dallas area and is an avid college and pro football enthusiast. When he is not working, he can be found spending time with his diverse family of 8 horses, ranging from show-winning Arabians to Paint rescues. Dr. Steve Miff is the President and CEO of Parkland Center for Clinical Innovation (PCCI), a leading, non-profit, data science, artificial intelligence and innovation organization affiliated with Parkland Health & Hospital System, one of the country's largest and most progressive safety-net hospitals. Spurred by his passion to use next-generation analytics and technology to help serve the most vulnerable and underserved residents, Steve and his team focus on leveraging technology, data science, and clinical expertise to obtain unique social-determinants-of-health data and incorporate those holistic, personal insights into point-of-care interventions. Steve was the recipient of The Community Council of Dallas' 2017 Social Innovator of the Year award and a finalist for the 2019 Dallas Business Journal most-admired healthcare CEO. Under his leadership, PCCI was named one of the 2019 Dallas Best Tech Startups by the Tech Tribune. Steve earned his PhD and MS degrees in biomedical engineering and a BA in economics from Northwestern University. He has been an adjunct professor of biomedical engineering for more than five years and has authored more than 100 thought leadership, white papers, and peer-reviewed publications. Before joining the nonprofit world, Steve served as the General Manager at Sg2, a national advanced analytics and consulting business serving over 1,200 leading healthcare systems, and as the Senior Vice President of clinical strategy, population health, and performance management at VHA (Vizient Inc.). He has also performed in various roles at the Rehabilitation Institute of Chicago, the National Institute of Standards and Technology, and St. Agnes Hospital System. Steve has served on the Senior Board of Examiners for the Baldrige National Quality Program and on the Executive Quest for Quality Prize Board Committee for the American Hospital Association. He currently serves on multiple other boards, including DFWHCF, NurseGrid and the SMU Big Data Advisory Board. Steve is a first generation American and he lives in Dallas with his wife of 23 years and their precocious seven-year old daughter. He is a data and technology geek, an avid sports enthusiast, world traveler, and a self-taught sous-chef and mixologist.

The Call to Action. Foreword. Preface. Contributors. About the Authors. List of Commonly Used Abbreviations. 1 Playbook Overview. 2 The Readiness Assessment. 3 Governance Track. 4 Legal/Policy Track. 5 Technology Platform Track. 6 Clinical Providers Track. 7 Community Partners Track. 8 Program Sustainability Track. 9 Final Notes. Key Documents. References. Index.

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