In Dallas, as in many cities, frequent users of emergency services often face underlying social issues. Coordination between health care and social services is often fragmented, but now an information-exchange portal launched by Parkland Health & Hospital System has found success in closing that gap for the city’s most vulnerable residents.

The Dallas Information Exchange Portal was launched in 2015 by the Parkland Center for Clinical Innovation, a health information technology research and development think tank created by Parkland Health & Hospital System. The Dallas IEP is a cloud-based system that allows social service organizations and Parkland providers to share patient data relating to medical history, patient encounter notes, services used and social issues, among other data, in an easy-to-navigate portal.

Because successful health care outcomes are so often linked to addressing the social determinants of health, the need for patients to connect with social service organizations, such as those providing housing and employment assistance, is “just as vital as health care services to long-term health,” says Steve Miff, president and CEO of the PCCI.

As of late last year, 87 organizations and 148,751 unique clients participated in the Dallas IEP, which had provided more than 800,000 services including housing, job training and food for clients. The goal is to expand the program to include 300 participating organizations, according to Miff.

Among the participating organizations that are seeing a benefit is the Metro Dallas Homeless Alliance. Data from MDHA iris recognition technology, which connects 38 agencies in Dallas, feeds into the Dallas IEP, enabling MDHA staff to locate clients — be they in prison or the emergency department. The MDHA also can communicate with Parkland physicians and service providers across the community via the Dallas IEP.

“We’re getting to really understand the body of knowledge of what our homeless clients are experiencing, where the encounters are happening and where we’re losing them,” says Cindy Crain, president and CEO of the MDHA. “Now it’s literally a click and a login [and] we can see a lot more.”

Of course, the goal of any data and analytics program is to work proactively to identify high-risk individuals and improve patient outcomes.

With that in mind, PCCI created a predictive-risk model for the Dallas pediatric asthma population, focusing on patients exposed to poor air quality who also had gaps in insurance, among other social factors that characterize those at risk of developing the disease.

That information is being used in three distinct ways: Case managers follow up with patients directly; alerts are sent into 17 physician-practice electronic health records in the area; and a mobile application sends texts to patients reminding them to take medications and maintain their appointment schedules.

For this population, the approach has resulted in a 40 percent reduction in hospitalizations, 36 percent reduction in ED visits and a $12 million reduction in patient-associated costs over 2½ years, according to Miff.

For the staff at Parkland, the ability to locate patients and work with community organizations has made a world of difference.

"We’re able to see patients have better outcomes [and] transition to a place in the community because we’ve linked arms and have hands on the patients outside the hospital,” says Marilyn Callies, senior vice president of transitional and post-acute services at Parkland Health & Hospital System.