Member Spotlights
Parkland Health & Hospital System
By Illysa Schrager
In 1894, Parkland Hospital opened its doors to citizens of Dallas County, Texas. More than 100 years later, Parkland Health& Hospital System (Parkland) has evolved into the cutting-edge public hospital system for all of Dallas County. Today, Parkland continues to embrace the organization’s mission and guiding principles which reflect its shared responsibility to achieve health care excellence for its patients and community, called the “Circles of Life” - Compassion, Integrity, Respect, Collaboration, Leadership, Excellence, and Stewardship; all of which represent the organization’s purpose. Parkland serves as the primary teaching hospital for the University of Texas Southwestern Medical Center.
Parkland is comprised of a tertiary and general practice public hospital with 12 satellite health centers located strategically throughout Dallas County. The health center system offers comprehensive care including adult, pediatric, geriatric and women’s health care. These community sites, operated by the Community Medicine Division, are known as the Community Oriented Primary Care Centers (COPC) and are co-located in many instances with the Women’s Health Centers (WHC) which provide prenatal, family planning, and gynecology care. The services provided in the COPCs include health and preventive maintenance check-ups, sick visits, and urgent care. The continuum of care focuses on education, prevention, and early intervention in an effort to reduce the need for acute hospital services. Each community site offers laboratory testing and some sites offer basic radiologic testing. Comprehensive diagnostic testing, specialty care, inpatient treatment and emergency services are available at the main hospital campus. The network of satellite health care centers, as well as mobile units, enables Parkland to offer high-quality, afford- able and accessible health care.
The Division of Women & Infants Specialty Health (WISH) oversees the provision of health care to women and children. Parkland’s patients receive care from WISH staff which includes more than 100 mid-level providers (advanced practice nurses specializing in women’s health) and many University of Texas Southwestern Medical School faculty and residents. Services span the entire continuum of care – outpatient, inpatient, urgent and emergency care – with referrals between providers and specialists to ensure that women receive the care they need.The administrative staff, made up of eight program and medical staffers, operate the WHCs.
Ten WHCs are strategically located throughout the under- served areas of Dallas County; nine WHC locations provide Title X family planning services. In addition to Title X, Parkland receives other grant funding to supplement the cost of services provided in the WHCs. All programs serve Medic- aid-eligible individuals with specific eligibility requirements and covered services for family planning, prenatal, and gynecology services. Processes, procedures, and protocols for care delivery are standardized across all WHCs with on site medical oversight and women’s health nurse practitioners who practice under standing delegation orders for family planning, gynecology, and prenatal services. Education and counseling services are provided by more than 30 bilingual women’s health educators who have successfully completed the Parkland Hospital System language/medical terminology proficiency examination in English and Spanish. Parkland has the largest residency programs in the country for obstetrics and gynecology services with 80 residents. It also has the largest group of midwives (45) and nurse practitioners specializing in OB/GYN services.
Parkland’s overall patient population is made up of ap- proximately 52% Hispanic, 30% African American, 13% Caucasian, 2% Asian, and 3% who classified themselves as “other.” Throughout the WHC sites, the number of family planning patients of Hispanic origin has increased and is now 83% of the total population served. Additionally, approximately 12% of that population is African American,4% Caucasian, and the remaining 1% is made up of other races. The population breakdown for the WHCs is reflective of a large percentage of patients who are provided prenatal care through Parkland’s WHCs and referred back to their prenatal clinic for initiation of post-partum family planning services within two to three weeks of delivery. Targeted family planning populations are adolescents and African Americans who have shown a consistent decline in accessing services over the last five years.
In 2012, Parkland’s WHCs had 239,825 patient visits. At its peak, Parkland served 40,000 unduplicated family planning patients through its nine WHC sites. In 2011, 70% of family planning patients were between the ages of 20 and 34. During that year, Parkland saw a peak in services provided at the WHCs, including: dispensing more than 100,000 packs of oral contraceptives; billing more than 1,600 tubal ligations to family planning; performing approximately 72,000 family planning visits; and preventing 6,083 adult and 1,096 adolescent pregnancies. Throughout that time, 29% of family planning patients chose oral contraceptives as their contraceptive method of choice; 21% chose to solely use condoms; 15% chose IUDs;and 9% chose Depo-Provera injections.
In 2009, Parkland implemented an electronic medical records(EMR) system to improve the quality of services delivered. Many months of planning and preparation went into the launch of the EMR, and numerous inpatient and ambulatory workgroups comprised of system-wide subject matter experts, physicians, mid-level providers, administration, nursing informatics specialists, and software consultants were convened to build every clinical aspect of the EMR. Since implementation, the use of the EMR has minimized preparation time for patient appointments, while increasing the efficiency of each patient visit.
Parkland has a Homeless Outreach Medical Services (HOMES) program comprised of mobile units traveling to various shelters and outreach locations providing pediatric and adult medical, dental, and social services. WISH partnered with HOMES from 2009-2011 to provide mobile family planning outreach services in specified underserved areas of Dallas County and community college campuses. This partnership was made possible through the award of Title X special project funding that enabled Parkland to focus on increasing access to family planning services for African Americans. More than 200 patients were provided comprehensive family planning services including annual exams, education and counseling, STD and HIV testing, and contraception at low or no cost.
The system has implemented processes to enable patients that are seen in the WHCs for prenatal, gynecology, and family planning services to consistently be seen by the same provider. Historically, patients were scheduled on a general template and would essentially be seen by the next available provider rather than receiving services from a consistent provider. After reviewing several patient satisfaction reports and compiling results over time, Parkland responded to negative patient feed- back about not being able to establish a rapport and medical relationship with their provider, by creating provider-specific templates so that patients could be assigned to the same provider. In most instances, the provider now starts with the patient during their prenatal care and sees the patient after delivery to initiate family planning. The satisfaction from patients as a result of this change has been evident through improved survey scores and patient retention.
In the fall of 2013, to further improve access to clinical services within the WHC sites, Parkland implemented an initiative to reduce annual exams for asymptomatic women from yearly to every three years, aligning with the American College of Obstetricians and Gynecologists’ recommendations. The WHCs are also implementing efforts across their health centers to monitor and reduce costs; reduce waiting time for new and annual appointments; reduce clinic dwell times (elapsed time from check in to check out); increase billing and collections; improve processes for sterilization paperwork; and increase patient satisfaction. Parkland also created one of the first high-risk ante-natal units in the nation and had the first neonatal intensive care unit in North Texas; it provides services to more than 1,220sick neonates annually. One of the unique things about family planning providers operating under a hospital system like Parkland is the amount of resources available to patients within their system. Parkland has the ability to refer patients internally for urgent, emergent, specialty and primary care services when medically indicated. There are financial services and Medicaid workers on site to assist patients with qualifying for various programs to cover their medical services. In addition, Parkland has a social work division to assist in identifying and addressing socioeconomic and psychosocial needs prevalent in varying patient populations. The system also has numerous community partnerships and reciprocal referral resources that Parkland patients are able to take advantage of daily. Parkland also receives generous tax-deductible donations from residents across Dallas County to support its work.
In 2011, the Texas legislature reduced overall funding for family planning by $73.6 million, eliminating Title V and XX funds. As a result, Parkland lost $5.1 million in grant funds reducing financial support for family planning services in eight of the 10 WHC sites. To continue serving patients, Parkland implemented mandatory co-pay for family planning services at the unfunded sites. Patients meeting eligibility criteria for Dallas County’s assistance program qualified for the$25 co-pay required at the time of service. Patients not meeting the assistance program qualifications were classified as self-pay and required to pay a minimum of $250 at the time of service. Patients unable to make the required payments at the scheduled visit were cancelled during the registration process. This service delivery change greatly affected Parkland’s family planning patient population. It began on January 15,2012, and lasted through May 14, 2013. On average,200 family planning appointments were cancelled monthly due to patients’ inability to pay. From January 15, 2012, through December 31, 2012, more than 3,100 patients cancelled their appointments because of their inability to pay$25 at the time of service. Additionally, the percentage of cancelled family planning patients who returned to Parkland’s health centers as prenatal patients rose to more than 10% within six months. Parkland’s senior leadership presented these findings to a state senate committee throughout the legislative sessions in 2013. Subsequently, much of the funding lost for family planning services was restored with expansion efforts for primary health care services.
Through its long-standing history and innovative practices serving patients across the Dallas metropolitan area, Parkland continues to serve as a model system for family planning providers, large hospital systems, and beyond.