Population Health Management

Population Health Management Managing the pandemic of multi-morbidity through population health management

Dr Helen Davies, NHS general practitioner, population health/digital lead and Cegedim Healthcare Solutions’ Clinical Advisory Board member, lays bare Population Health Management and steps for NHS organisations to achieve it

What is Population Health Management? It is sometimes described in vague terms that make it sound like public health, or - what we have always done as clinicians - attempting to do evidence-based, patientcentred practice. What it is actually about is a radical shift in care delivery that starts with the needs of a population, not the capability and configuration of a string of isolated providers. It is a model for the planning and delivery of proactive, anticipatory care to achieve maximum impact within collective resources. It is an exercise in service design for the whole population, one cohort at a time, using data and analytics to guide us.

So, why is it so important now? There is an increasing body of evidence internationally that healthcare is delivered best, if it’s done as an integrated care system across various health and care providers, with person-centred care at its centre. The data also tells us it is multi-morbidity which is currently driving demand and cost within the NHS: more than one in four of the adult population in England currently lives with two or more conditions. Living with numerous and often complex health problems is becoming the norm for older people and those from disadvantaged communities. Some conditions cluster together and people can experience many different combinations of conditions, the impact of which can also vary.

Yet, despite considerable diversity in their disease profile and circumstances, people with multiple conditions frequently share common problems. They may have reduced mobility, chronic pain, shrinking social networks, incapacity to engage with work, and lower mental wellbeing. To date, these problems have not been well-addressed by services or research.

We tend to organise services around single conditions; doctors train in specialties; and research and decision support tends to be organised one disease at a time. This siloed way of thinking about morbidity doesn’t reflect the real world. People with multiple conditions want greater service integration, more person-centred, holistic care, and better support for mental wellbeing. To address this, innovative ways of intervening are needed; a Population Health Management approach is needed. Here is how we can succeed in its delivery.

Population health management laid bare There is an overlap with Population Health (public health) which the Faculty of Public Health defines as “the science and art of preventing disease, prolonging life and promoting health and wellbeing, through the organised efforts of society”.

Population Health Management (PHM) focuses on groups of people with shared characteristics (a cohort) and the design and delivery of holistic care of that cohort and each person within it. In this it links public health with direct patient care. This proven approach uses datadriven planning (quantitative and qualitative) and includes segmentation, stratification and ‘impactability modelling’ to identify which specific ‘at risk’ cohorts to target. The concepts of integration are key to this redesigned service and the concept of working closely with users and communities themselves. The PHM approach is anticipatory and proactive to achieve maximum impact and uses collective system resources to address wider factors such as environment, e.g. housing, transport, green space, as well as social factors such as education, employment, isolation, and safety – and behaviours, e.g. smoking, diet, and alcohol – all of which we know are important determinants of health and wellbeing.

It is about using data, insights and evidence of best practice to co-design and deliver integrated models of care working with health, social, community, voluntary and private sector and the public themselves.

Enablers to PHM The implementation of the 2021 Health and Care Act puts in place enablers to make it easier for health and care organisations to deliver joined-up care for people who rely on multiple services. These include enablers such as engaged leadership with aligned incentives, joined-up data and IT, facilitative decisionmaking processes, lines of accountability and information governance in place.

Equally important as these structures and processes, we must not forget that the workforce aspects to this change are key. People are the ones who are both delivering and receiving care, so we must ensure that we take people with us, that they are involved in and feel part of the journey.

Despite considerable diversity in their disease profile and circumstances, people with multiple conditions frequently share common problems

Steps to Deliver PHM People often wonder where and how to start, but I often say to simply start where you are with what you have. We cannot use PHM to address the needs of the whole population in one go.

Step one: is to prioritise, use data analysis or community stories to find priority areas - i.e. an area of unwarranted high cost or high demand, or unmet need or inequality of care. The wider and richer the linked system data, the more informed this decision making can be, but you need to get on with it with what you have – using your ‘best available insights’. This can be cross referenced to compare against similar practices/areas for example, fingertips data and Joint Strategic Needs Assessment (JSNA).

Step two: is the cohort. Use data analysis (stratification and impactability modelling) to identify a cohort within your priority area for whom there is the best opportunity to improve the quality, efficiency or equity of care. This may include a particular condition(s), or more likely a group of conditions or just “comorbidity” or “complex needs”, within a geographic area, a particular demographic (age, ethnicity) or those at risk of a hospital or care home admission.

Step three: use a wide lens to include the broadest range of available existing insights and include the patient’s and carer voice to understand your cohort. Seeing it from the patient/citizen side will address wider determinants of health and consider health inequalities. Use this broad view to get a clear picture of the existing resources and services.

Step four: designing. In designing a new model of care to deliver better outcomes, ask questions such as: What are the needs of the cohort? What outcomes do you need to see in order to meet these needs? What activities do you need to do to achieve the outcomes?

In the past the NHS has worked in silos of care where success is judged by the success of the institutions within it, measured by individual organisation activity and financial balance sheets.

What resources and skills do you need to invest to do those activities?

Step five in delivering PHM is implementation: the ‘how’, ‘who’ and ‘what’ involved in making it happen. You need to ensure necessary buy-in from system leadership and stakeholder organisations for the support, co-operation and IG processes to deliver the plan. From the outset, plan how you will measure the outputs and outcomes including both care provider and patient/user feedback. Keep the process agile, adapt as you learn.

Finally, Step six is about evaluation and expansion. You need to evaluate the process and the outcomes, including: Did you reach the target group? Did you achieve the intended outcomes/outputs? What worked well and what can you improve? Do you need to make any changes based on your evaluation? How can you scale up/share your plan?

Trust in the process. Involve all relevant stakeholders and the patient/citizen at every stage from information gathering, planning and designing to delivery and evaluation. Make sure to combine best laid plans with pragmatic delivery.

Conclusion The increasing pressure on the NHS makes it a clear necessity to do things differently if it is to endure. In the past the NHS has worked in silos of care where success is judged by the success of the institutions within it, measured by individual organisation activity and financial balance sheets. This has resulted in perverse incentives, gaps and overlaps, and inefficient and disjointed care.

Instead the health and care system needs to collectively manage and be measured by the health and wellbeing outcomes of the population being served, moving from reactive to proactive and anticipatory care, targeting care to meet the requirements of different groups and personalising care to the individual needs, which will require a cultural shift for healthcare professionals and patients.

Our care system needs to rise to the challenge of ensuring that integrated care is a success. Population Health Management is key to enable the delivery of Integrated Care Systems and needs to become embedded in the day-to-day as the way we do things, to target care appropriately, effectively and efficiently. L

FURTHER INFORMATION

www.cegedim-healthcare.co.uk/ blog/clinical-advisory-board

www.linkedin.com/in/helendavies-0b490a120/