In medical history, the year 2020 will be remembered for the COVID-19 pandemic. It will be remembered for the everyday heroism of care providers, the rapid creation of vaccines for worldwide inoculation, the exponential growth in virtual care/telemedicine, and for exposing the ongoing challenges of achieving health equity—particularly for underserved populations.

While many health system leaders have known the importance of social determinants of health (SDOH), 2020 was when a significant number of health systems started to fully integrate SDOH identification and management into their end-to-end care management processes. While these types of clinical care and community-based service integrations might go by many names (ACOs, population health management, etc.), we call them connected communities of care (CCC).

For us, CCCs addresses critical gaps between clinical care and community services in the current healthcare delivery system, with the goal of positively impacting whole-person health. They are comprised of technology platforms, community alliances, and governance for cross-sector data sharing, care coordination and community alignment.

Through weekly meetings with hospital and health system leaders, Healthbox often heard about the significant social disparities further exposed by COVID-19. Leading providers reacted quickly by reaching out to community organizations, ramping up analytics and collaborating with competing health systems. Last year, Dallas-based Parkland Center for Clinical Innovation (PCCI) created a COVID-19 Vulnerability Index to measure communities’ vulnerability to COVID-19 by tracking and analyzing socioeconomic, clinical, mobility and demographic risk factors. Local healthcare providers are using the index as a tool to better tailor their COVID-19 response to the neighborhoods that need it most, deploy more testing and education in at-risk areas, and plan culturally sensitive initiatives to address infection disparities in Black and Latinx communities that have been disproportionally impacted by the pandemic.

Healthbox leaders recognized this important shift in bridging the community and clinical worlds, and we increased our SDOH focus through thought leadership and client-facing services. Most critically, we developed a strategic partnership with PCCI, a national leader in SDOH, data science and vulnerable populations. PCCI has 10 years of relevant experience in addressing SDOH across Dallas County, including six years of comprehensive data across dozens of providers and community organizations that help support a new model and strategy for addressing SDOH.

There are endless data points showing how we have passed the tipping point for addressing SDOH and integrating community-based services into end-to-end care. Here are a just a few of those, along with Healthbox resources on the topic:


Improving Whole-Person Health While Reducing Overall Cost of Care

  • Social determinants of health factors influence ~40% of health outcomes and costs:

    • Food-insecure patients are 2.4x more likely to report multiple ER visits.
    • Transportation-challenged patients are 2.2x more likely to report an inpatient stay.

    Example: Georgia State University will use a randomized trial to test several low-cost ways of improving transportation opportunities for low-income urban diabetic patients, including providing public transit vouchers, Lyft ride-share credits, a cash benefit or mobility counseling compared with usual medical care alone.


Focusing Services on the Highest-Risk Communities

  • Three core data requirements are essential to achieve this impact:

    • Data granularity: To understand gaps/needs, data analysis must occur at the census track or the block group level.
    • Regular data refresh: A CHNA is performed every three years, and even the best ones become outdated quickly. That can’t be the case when actively managing a CCC, so a regular commitment to data is needed.
    • Enhanced analysis of SDOH: While SDOH is a component of a CHNA, there’s a heavier emphasis on it in a CCC, since identifying causal relationships to specific clinical conditions is essential.

      Example: Missing data granularity is impacting the ability to track and therefore focus vaccine distribution on the highest-risk communities.


Improving Reach and Engagement via Trusted Communication Channels  

  • CCC communication networks linking social service, community and healthcare providers are extremely important, since they represent a highly effective and efficient mechanism to disseminate leading practice information aimed directly at high-risk populations. This will be especially vital as communities develop COVID-19 vaccination strategies.

    Example: The CCP project in Chicago designed a communication campaign that includes town hall meetings, videos and infographics on how to care for oneself and help protect others during the pandemic.


Together, Healthbox and PCCI are supporting ACO and population health leaders at healthcare systems who seek to initiate new or improve existing clinical/community-based partnerships. Anchored in the framework that is described in the 2020 HIMSS/PCCI published book “Building CCCs,” we are able to take action on SDOH to ensure that an individual’s medical and non-medical needs are both addressed through the collaboration of community organizations, providers and patients.

Healthbox, a HIMSS Solution and healthcare advisory firm, drives innovation from the inside and out, helping organizations build internal innovation programs, assess the potential of employee-led projects, and look to the market to find solutions to implement or invest in.

Using Connected Communities of Care to Take Action on Social Determinants of Health


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