By John Gurnett
Improving the overall health of the UK population during the pandemic has put the onus on the NHS to establish effective data-driven strategies to create an impactful care system. A proposed model of population health management (PHM), comprising a four-pronged strategy for data set capture, can help stakeholders gain crucial insight to deliver personalised care, timely interventions, and reduce health inequity.
The current scenario of population health management PHM is an approach aimed at bettering the overall health of a local or national population, through improving care coordination, delivery, and outcomes—while improving health equity. In its entirety, PHM focuses on a more comprehensive set of determinants of health as only 20% of a person’s health outcomes are directly attributable to the ability to access good quality medical care. Effective PHM emphasises the importance of the social and economic determinants of health, as well as the crucial role local communities have to play.
Foundationally, PHM is powered by data to identify individuals at risk of illness and engage them in personalised interventions aimed at preventing or managing illness—through segmentation and stratification techniques. The UK’s local health and social care systems have started using data from their collective resources to design new models of proactive care and deliver improvements in community health and wellbeing. But, they are not able to effectively manage and derive valuable insights from real-world data, as the current technologies, processes, and clinical systems are unable to deal with the huge volume of data being generated. To solve these data challenges, healthcare organisations need to embrace disruptive data technologies which enable them with an effective data lifecycle model aimed at driving population health outcomes.
The future of a data-powered PHM
The UK health system has undergone a massive transformation through the emergence of Integrated Care Systems(ICSs), whose purpose is to improve care outcomes and ensure that people lead healthier lives. ICSs target improvements in wellbeing, physical and mental health outcomes, and address and improve health equity—at the community level.
Through leadership development, knowledge, and skills, NHS England’s Population Health Management Development Programme focuses on the development of leadership, knowledge, and skills for employing the proper use of data and analysis for driving better decisions. Specifically, for tailored health inventions for improved health access, engagement, experience, and outcomes. Additionally, in the NHS’ Long Term Plan, local organisations will increase their focus on delivering increased population health outcomes.
The ICSs have made it possible for all health and care organisations to come together as partnerships that can plan and deliver much more coordinated and streamlined care to the citizens of the UK. According to GP Dr. Hein Le Roux, Deputy Medical Director for NHS England South West and One Gloucestershire ICS Quality Improvement Clinical Lead:
“The enormous benefits of closer partnerships within integrated care systems have led to crucial linked-data emerging which is highlighting the highest risk and most underserved population groups. Health and care professionals using a PHM approach are regularly amazed at what the data can tell them and how this transforms their service models.”
To meet the need for personalised healthcare, the health system needs access to unified patient data, which can provide greater patient engagement and experience throughout the care journey. More personalised treatments and tracking of care—from start to finish—close care gaps, while building a deeper understanding of the local population.
PHM uses historical and current data to understand what factors are driving poor outcomes in different population groups. By designing proactive care models, local health and care services can improve health and wellbeing over the longer term. An ideal model of population health management consists of a four-pronged approach—capturing the right data sets, gaining invaluable insights, delivering more personalised care, and further eradicating disparities in health equality within the UK population.
To facilitate effective outcome-based PHM, it is critical to:
● Connect population-wide electronic data records with the right set of infrastructure, tools, and applications.
● Collect the latest data on various factors such as medications provided, problems diagnosed, lab results along with the associated timelines and social factors like housing, education, ease of accessibility to healthcare services, etc.
● Gain real-time insights and intelligence by using a defined set of clinical protocols for the collected data record to determine which patients are overdue for particular types of preventive and chronic care.
● Design adequate intervention initiatives required to address the gaps and inequalities highlighted through the data records. This should be accompanied by regular monitoring and tracking of all such initiatives and their effectiveness.
Automated software can detect patients requiring health services to improve care management; and automatically send out a call, email, or text message urging them to make an appointment with their health and social care providers. Such patient engagement and exchange of information between the regional and local bodies enhances PHM, and can improve both patient and community care outcomes. It also ensures that people are provided with integrated and proactive care services in environments that are closer to their homes.
Driving population health outcomes doesn’t simply need a new manner of thinking— it requires a new way of executing care setup, combined with pioneering initiatives across the care continuum.
A seamless procedure of data exchange, timely analytics, data-driven care coordination, better-managed workloads, and a heavier focus on improving the quality of care can help organisations to skyrocket the outcomes of their population health improvement initiatives.