Hertfordshire and West Essex
Sustainability and Transformation Partnership
POPULATION HEALTH
MANAGEMENT
JIM MCMANUS
HEALTH AND WELLBEING BOARD, MARCH 2019
APPENDIX A
2
Commissioning and Delivery – The Mechanics
A common purpose
There are five overall aims of Population Health Management:
• Improve the health and well-being of the population
• Enhance experience of care and support
• Reduce per capita cost of care and improve productivity
• Increase the well-being and engagement of the workforce
• Address health and care inequalities
Why is it important?
The Triple Aim - What
Better care for
Individuals
Better health for
PopulationsLower Cost
Wider
determinants of
health
Person
centred
care
Social
movement
for health
A framework for improving health and
care at scale1. Achieving a best start for children and
families.
2. Achieving a fully engaged scenario withcommunities and people mobilised forimproving their health and wellbeing.
3. Address the unwarranted variation inmanagement of risk factors and carepathways.
4. Proactively meeting demand byidentifying and supporting individualsand families with complex needs.
5. Improving the wider determinants ofhealth by embedding health in allpolicies including housing, employment,planning and licensing, transport, andadvocating for national healthy publicpolicies.
This work stream, whilst delivering specific programmes, is also linked to all other portfolios
of the ICS
A common definition
Population Health is an approach aimed at improving the health of an entire population.
It is about improving the physical and mental health outcomes and wellbeing of people,
whilst reducing health inequalities within and across a defined population. It includes
action to reduce the occurrence of ill-health, including addressing wider determinants of
health, and requires working with communities and partner agencies.
Population Health Management improves population health by data driven planning and
delivery of proactive care to achieve maximum impact.
It includes segmentation, stratification and impactabilty modelling to identify local ‘at risk’
cohorts - and, in turn, designing and targeting interventions to prevent ill-health and to
improve care and support for people with ongoing health conditions and reducing
unwarranted variations in outcomes.
There are 3 core capabilities for Population Health Management
What are the basic building blocks that
must be in place?
• Organisational Factors - defined
population, shared leadership &
decision making structure
• Digitalised care providers and
common health and care record
• Integrated data architecture and
single version of the truth
• Information Governance that
ensures data is shared safely, securely
and legally
Opportunities to improve care quality,
efficiency and equity
• Supporting capabilities such as
advanced analytical tools and
software and system wide multi-
disciplinary analytical teams,
supplemented by specialist skills
• Analyses - to understand health and
wellbeing needs of the population,
opportunities to improve care, and
manage risk
• Interpretation of evidence to identify
targeted, high impact interventions
Care models focusing on proactive
interventions to prevent illness, reduce
the risk of hospitalisation and address
inequalities
• Care model design - delivery of
integrated personalised care and
interventions tailored to population
needs
• Community well-being - asset based
approach, social prescribing and
social value projects
• Workforce development - upskilling
teams, realigning and creating new
roles
Infrastructure Intelligence Interventions
Neighbourhood
~50k
• Multi-disciplinary teams using real-time risk stratification to flag
interventions for populations and individuals.
• Using person level data for case identification and management
and to optimise how people are directed through their pathway of
care.
Place
~250-500k
• In-depth segmentation, risk stratification, and actuarial analysis to
identify opportunities to redesign care and develop proactive
interventions to prevent illness and reduce hospitalisation.
• Integrated Care Providers building capability to track people and
combine real-time workforce, bed capacity and activity data to identify
productivity opportunities
System
1+m
• Population Health Strategy based on whole population health and care
needs assessment and gap analysis to identify overall priorities.
• Whole population profiling and system modelling to understand likely
future health outcomes and where system wide action may be
effective.
• Commissioning of outcome based care.
Individual
• Individual having access to and being able to amend their own care
record enabling self care.
• Health and care professionals across settings having access to an
individual’s care record to support personalised care, PHBs and
targeted prevention.
Embedding population health management across all tiers
within a system
More timely joined up data flows and automated analyses will offer insight to enable more responsive anticipatory care, but it will be
crucial that systems look to release and streamline capacity and capability to more effectively support care coordination and delivery.
Neighbourhood
~50k
• VCFS organisations and community assets mobilised to support
neighbourhood teams
• Wider public sector services aligned (e.g housing, employment
support)
• Organising public health and preventative services
Place
~250-500k
• Working with district councils to address
• Local place based policies on housing, transport, air quality
• Working with housing associations
• Engaging with schools and colleges
• Partnering with local businesses on work and health
• Place based analysis of needs and determinants of health
System
1+m
• Embedding health and wellbeing into the wider public services reform
agenda (including Govt Depts e.g DWP)
• Shared programme of work with Enterprise Partnerships
• ICS-wide Health and Wellbeing Board to champion population health
• System-wide JSNA on HWB and determinants of health
• Ensuring resource allocation for prevention and improving wider
determinants
Individual
• Health and care professionals across are able to have strengths based
conversations with individuals
• They are able to identify social factors and their impact on individual’s health
• Frontline care providers become better advocates for socio economic and
environmental determinants (Seeds) of health and wellbeing
Embedding social economic and environmental determinants across
all tiers of the system
• At strategic and operational level this needs to
identify actions for different agencies, from
the NHS to local authorities, third sector and
others. How well we understand our
competencies, the fact we ALL have a role –
and there are STRONG clinical components to
this for EVERY clinician, and who is best placed
to do what will determine whether this
approach ever gets off the ground
12
System Approach
13
3. Reducing the need and spend curve:
Preventing avoidable spend in public service
Highest cost.
Reduce and delay
Need ehere
Reduce or delay need here
Intervene here before need
escalates
Volume of
spend
Severity of need
Existing curve
3. The Aim from reducing the spend curve
Volume of
spend and
cost
Severity
Existing curve
The Achievable
curve?
Healthy Diagnosed
Condition
In treatment
Complex
Place based, social
prescribing,
social marketingPathway
Wrap round
care
co-ordinated
approach
Population Health Management• Proactive application of strategies and interventions to
defined groups of individuals, to support prevention and
chronic disease management - whilst managing costs
• This includes –
assessing population across the continuum of care
stratification and modelling of defined ‘at risk’
populations
development of management plans depending on each
groups needs
surveillance
performance management etc
• STRATIFYING – By need/risk/severity
• SEGMENTING – By lifecourse stage
• IMPACTABILITY – What will be the outcome of
doing this and WHERE -primary care,
secondary care,social care, community
17
Generally well
Long term
conditions /
Long term
needs
Complexity of
LTC(s)
and/or disability
Low
riskHigh risk Low risk High risk Low risk High risk
SEGMENT
Children and
Young People
• Neonates
• Infants
• Toddlers
• Children
• Adolescents
STRATUM STRATUM STRATUM
SEGMENT
Working Age
Adults
• Young
• Middle aged
• Older working
age
SEGMENT
Older People
• 65-80
• 80-90
• 90+22/02/19 Dr Steve Laitner
With thanks to Steve
Laitner for this slide
Stratification• People who are generally fit and well need access to high quality
and effective primary prevention interventions in order to prevent disease and stay well.
For example, childcare, education, family support, physical activity, employment, housing, social interactions, diet, avoiding smoking and drugs, safe alcohol consumption
• People with long term conditions need to be identified early to help them stay well and prevent future complications.
For example through community based help, personalised care planning, self-management support, medicine management and secondary prevention services.
• People with complex comorbidities need personalised care to maintain their quality of life.
Population Health Management
Case
Management
Specialist Disease Management
Supported Self Care
Population-wide prevention
21
Robert
Wood
Johnson
Foundation,
2014
Requires a collaborative strategy
between leaders in healthcare,
politics, charity, education, and
business
True Population
Health
Management
Children and Young
People
Working Age Adults
Older People
Population health cube
© 2017 National Association of Primary Care 22/02/19 Dr Steve Laitner
23
Population segmentation reveals vast differences in resource
consumption by difference groups of population
Source: Kent Integrated Dataset, Carnall Farrar analysis *NOTE: Excludes Children’s Social Care 8
Generally well/good wellbeingLong term condition(s)/social
needs
Complexity of LTC(s)/ social
need and/or with disability
Children and
young people*
Working age
adults
Older people
- -Population,
Thousands
Spend, £
Millions
0.3 1.9
Spend per head, £
1.7 10.3
0.1 0.31.0 0.9
17.6 30.2
4.3 10.5
8.6 3.6
16.7 5.8
0.7 1.3
7,507
5,948
4,000940
1,721
2,445
425
348
1,824
50k population in Kent and Medway
INCREMENTAL APRPOACH
Focus on gains which can be made easily and systematically, identify areas where most “health gain” can be made
This is NOT about saying “it’s all about wider determinants” or “well we have to do primary prevention” IT IS NOT
There are cohorts of people already morbid, in the system, where evidence shows this approach can produce benefits in short, medium AND long term
24
• Worth noting that PHM is not new.
– Eg Stratifying group populations by risk is something we already do
– Disease management programmes exist for those identified
• What is different now?
– We want to work with partners and develop more co-ordinated approaches to improving population health, reduce costs etc –need to share data to do this
– New STP/ICS geographies – including 30-50k ‘neighbourhoods’
– Technological advances…
Four Core Components
Mindset. Evidence. Culture. Interventions
• Mindset
– Workforce Attitude, Culture and Skills
• Evidence
– Analytics, Informatics and Data – getting the data to help drive decisions and approaches
– Evidence of what is effective
• Culture
– A culture which puts this approach into action every time
• Interventions
– Pathways – being able to pathway people and shifting investments to make it happen
– Interventions – knowing the intervention
Some groundrules• Don’t start with primary prevention, start with
the populations who are already in the
system, and where gains could be made most
quickly and easily
• What can be made “routine”? (eg smoking
cessation as core part of respiratory care)
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Four Critical Success Factors, Many Hurdles Along the Way
Achieve Data Transparency to
Manage Utilization
• Hard to arm physicians with information due to
limited transparency provided by payers
• Difficult to link and reconcile disparate data sets
using data warehouse solutions
• Internal clinical and financial systems constrains
visibility to utilization inside organization
Prioritize Patients at Highest
Risk of Poor Cost and Quality Outcomes
• Predictive analytics required to forecast outcomes
with accuracy not a core competency of EMR,
financial system vendors, or providers
• Lack of robust benchmarks prevents identification
of actionable opportunities based upon gap to
benchmark
• Limited visibility into psycho social factors
Focus Interventions on Highest
Prioritized Opportunities
• Lack of integration between analytical and
workflow tools prevents effective execution
• Difficult to quickly identify and engage the
appropriate resources for each intervention
• Limited ability to bring together timely clinical
and financial risk data for clinicians at the point
of care
Measure Impact of Interventions and
Continuously Improve
• Difficulty linking cost and utilization data
hinders ability to track and trend PMPM costs
• Data complexity prevents routine analyses with
frequency required for course correction and
continuous improvement
• Difficulty connecting productivity of care
managers to outcomes and return on
investment
Clinic
ian
Com
missi
oner
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