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How to Build a Connected Community to Address Social Determinants of Health

Analysis  |  By Mandy Roth  
   April 21, 2020

Parkland Center for Clinical Innovation shares its framework that helped Dallas to become one of the first metropolitan regions to scale a clinical and community partnership using a web-based information exchange.

This article appears in the May/June 2020 edition of HealthLeaders magazine. 

Many hospitals and healthcare systems have an interest in addressing social determinants of health (SDOH), yet few can claim the positive results Parkland Center for Clinical Innovation (PCCI) has experienced. By addressing food insecurity for individuals with hypertension and diabetes, for example, related hospital readmissions have been reduced by 50%.

It was a long road to produce such measurable results. It took five years for PCCI, a nonprofit which is closely affiliated with Parkland Health and Hospital System, to navigate the terrain that helped Dallas become one of the first metropolitan regions to develop and scale the clinical and community partnership that is essential to an effective SDOH program.

To help other organizations accelerate their efforts, PCCI has introduced two innovations. First, is a 300-page playbook that provides a step-by step process to building a connected community. Second, is the technology that enables efficient referrals and communication between participating health systems and community agencies: a soon-to-be patented, secure web-based information exchange.

A Playbook to Kick Off an SDOH Initiative

For the last couple of years, SDOH has been a big "buzzword," says PCCI President and CEO Steve Miff, PhD, who is a participant in the HealthLeaders Innovation Exchange, an annual gathering of healthcare innovators who convene to discuss industry challenges and solutions with their peers.

Healthcare leaders are now "moving from talk into action," Miff says. "We believe that we are at an inflection point, and that providers and community leaders can truly develop new engagement strategies to address a person's [total] needs," he says. "Folks have moved from sort of just nodding their heads and saying, 'Yes, this is something important' to [asking], 'Where and how do we start?' "

The new guide is designed to do just that and creates shortcuts based on "the scars and bruises that we've accumulated along the way," says Miff. Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations, a HIMSS publication, was published in March. It presents an organized approach to designing and developing a connected community, says Miff, who wrote the book with PCCI Vice President Keith Kosel, PhD, MHSA, MBA.

Access to healthy food, housing, transportation, medication, and support are among the factors that contribute to a person's health, yet fall out of the traditional purview of hospitals and health systems. To coordinate services with organizations dedicated to these endeavors, Miff says it is necessary to:

  • Understand the needs of individuals across the community.
  • Build a referral network so clinicians and community organizations know what resources exist.
  • Create a mechanism—the web-based information exchange—to coordinate referrals and  provide information back to referral sources.

In reconstructing what worked for the Dallas initiative, the authors enumerate six distinct factors that contribute to building effective care communities:

  1. Governance: Creating the right coalition is essential to determine how to best share data, obtain consent, and build capacity.
  2. Legal/policy: A framework to deal with issues related to HIPAA, privacy protections, technology partners, and more is necessary.
  3. Technology platform infrastructure: Activities encompass a broad range of issues, including defining underlying business requirements; addressing user needs; determining security, data analytics, and storage requirements; and much more.
  4. Clinical providers: Engaging frontline clinical staff and determining workflows are among the essential considerations.
  5. Community partners: Engaging organizational leadership and creating a mechanism for ongoing training are vital, particularly given variations in the types of services that community-based organizations provide, says Miff.
  6. Program sustainability: Beyond the initial funding, how do you sustain and grow a program as it picks up momentum?

One big lesson: "We underappreciated the amount of time and ongoing training that needs to occur for this to be sustainable because of the significant amount of turnover that occurs in most community-based organizations," says Miff. Because many rely on volunteers, an ongoing cadence of training should be established to ensure new individuals understand the bigger picture, he says.

Another essential learning was that an initiative can get more mileage by partnering with umbrella organizations early in the process. For example, PCCI engaged the North Texas Food Bank, which coordinates services among multiple community food pantries. A bigger footprint leads to greater initial success, says Miff.

Technology: Behind the Scenes

One key to PCCI's success is the technology they created to support the SDOH initiative.

"Technology is a key element of an effective connected community of care to digitally link healthcare providers with community-based organizations and other critical local and regional entities," explains Miff. One challenge to SDOH programs is a communal platform to exchange information.

To meet this need, PCCI developed a comprehensive SDOH case management digital platform known as Pieces IRIS, which has a patent pending and is now exclusively licensed by Pieces Technology.

If, for example, a provider wants to refer a patient with hypertension to a food pantry, a quick look at the directory on a computer, tablet, or smartphone app enables the clinician to find a location convenient to the patient, Miff explains. The platform notifies the food pantry to expect a visit from the patient and to guide them toward specific food selections. The patient has a "warm handoff" with the name of someone at the pantry who is expecting them, along with the location and hours.

Transportation can also be arranged on the platform, if needed. Once the patient visits the pantry, the referring provider receives an alert, noting that the patient has followed through.

"This closed-loop comprehensive case management is important," says Miff "because we were never before able to effectively connect and exchange information with those who provide these critical resources in the community." The following elements, he says, are essential to any SDOH technology:

  • A cloud-based platform, which provides accessibility anywhere the Internet is available
  • An updated geo-mapped, referral directory that delivers accurate locations, hours, and provides a summary of active programs. During the COVID-19 pandemic, for instance, many community-based organizations changed hours or closed due to lack of supplies or volunteers. The directory prevents providers from referring individuals to places where no service exists.
  • Simple, configurable intake forms, including eligibility criteria
  • The opportunity to generate referrals from any participating organization
  • HIPAA compliance and 2-factor security
  • Multiple levels of patient consent
  • Multiple user roles to handle sensitive information
  • Customizable quick reports
  • CMS certification for use with federal grants

"Health begins where we live, learn, work, and play," says Miff. "The only way to achieve that is to figure out how to create connected communities. I believe that's the future of health."

The HealthLeaders Innovation Exchange will be held in Boston, July 15–17. It is one of several healthcare thought leadership and networking events that HealthLeaders holds annually. Our Innovation Exchange brings together CMOs, CMIOs, CIOs, Population Health VPs, and other dedicated leadership for intimate discussion on this strategic priority. The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at For more information, please visit HealthLeaders Exchanges

“We believe that we are at an inflection point, and that providers and community leaders can truly develop new engagement strategies to address a person's [total] needs.”

Mandy Roth is the innovations editor at HealthLeaders.

Photo credit: Pictured above: Steve Miff, PhD, is the President and CEO at Parkland Center for Clinical Innovation (PCCI). (Photo credit: David Hartig.)


A  playbook offers step-by-step guidance to help hospitals and health systems build effective connections with community organizations to address social determinants of health.

A web-based technology platform provides the essential infrastructure to enhance referrals and communication between organizations.

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