PCCI Connected Communities
of Care

PCCI Connected Communities of Care (CCC) is a social determinants of health (SDOH) based framework designed to describe a local ecosystem of health-related organizations to coordinate services that span the clinical-to-non-clinical continuum. Parkland Center for Clinical Innovation, the strategies founder, hopes CCC will reduce the cost of utilization for unnecessary care.

What factors are essential for effective cross-sector alignment?

Shared Purpose

  • Coalition members serve a different point in the health care process to take a coordinated approach to addressing SDOH.
  • PCCI CCC mainly contracts with two major community-based organizations (North TX Food Bank and MDHA), which then can sub-contracts with other CBOs to join indirectly.
  • Clinical providers and community partners are two of the six distinct factors that contribute to building effective care communities with a focus on engaging frontline workers and creating a mechanism for ongoing training in community-based organizations.


  • Governance is cited as one of the six distinct factors that contribute to building effective care communities.
  • The coalition has an advisory group, but it did not have “an explicit governance function,” which created some challenges with setting expectations for participating orgs.
  • The governance model includes an anchor organization (compared to treating all organizations equally); the anchor organization has “enough gravitas and enough market voice” to “make things happen.”


  • Data sharing was the “strongest” element of the four factors (the coalition is a tech-based referral hub). Their web-based technology platform (IRIS) provides the essential infrastructure to enhance referrals and communication between organizations (cloud-based, geo-mapping, referral generating).
  • Health care organizations have more capacity for data sharing/tracking;  the coalition instills that they have to participate in data sharing “to be a full standing member.”

Finance and Sustainability

  • PCCI CCC is mostly funded by private or non-profit grants; In 2017, they received a $4.5 million Accountable Health Communities (AHC) grant from the Centers for Medicare & Medicaid Services.
  • IRIS software portal originally created through an endowment from Caruth foundation.
  • The coalition is focused on developing data and reports that will show payers and insurers that the service will reduce costs; this is the ultimate sustainable funding source.

Integration of Health Equity

  • No mention of health equity in early founding, but is an implied assumption among members
  • Addresses social determinants of health to reduce costs of care and improve quality of life, starting with early leadership
  • Plans to measure block-level community vulnerability with predictive and analytic tools

Community Trust and Accountability

  • Requires member organizations to complete all data reports in order to be full standing members

Measures of Success

  • Confirming a referral was completed
  • Wants to know more details and to “tell the complete story”

Outcomes Achieved

  • Streamlined the contracting process leading to later programmatic success
  • Engaged hundreds of CBOs to facilitate referrals and provide broad network for clients