Leadership and the case for change
The starting point of this PHM story was consensus at senior leadership level that there was a powerful case for change. Time was spent crafting a business case for change around which the multi-disciplinary leadership team could coalesce and sign-up to.
The debate started with a hypothesis. This particular hypothesis was that people with complex needs and escalating risks made significant demands on the local health and care system and that these demands weighed most heavily in primary care, community care and social care settings.
Early data analysis showed that service utilisation in acute hospital settings was particularly high for people with complex needs. The senior leadership team made a commitment to address this. Leadership had a vision for an anticipatory model of care aimed at identifying complex needs individuals with the aim of transforming services in order that these patients were better supported.
Leadership embraced change. Having done so they invested both financially and emotionally.
It’s a team game
Leadership is key, but from an early stage it was recognised that PHM is a team game. You need to build a team culture to support PHM. Right from the beginning time and care was taken to identify the right members of that team.
In this case that team was built around the engagement of clinicians, analysts and ‘business’ experts. In short what was established was what Sylvia and Vigil [1] refer to as a PopHealth Troika (PHT)™. Relationships within the team were built on mutual trust and each member had a clear understanding of their role and the expectations of them. Consequently, a safe space was created in which team members could innovate.
The detail matters
It was clear from the outset of the project that different stakeholders had differing views on was meant by the term complex. Time was spent establishing the qualifying criteria. The process for reaching consensus was iterative and the results expressed pictorially.
This was a hugely important part of the process as it formed the basis upon which the process of data discovery could commence.
Having agreed the qualification criteria, work started in earnest in terms of identifying the data and data sources needed to successfully identify complex cohorts. This required expert and dedicated analytical support. The ‘Troika’ worked together with the aim of identifying markers that might constitute an ontological approach to defining complexity.
Data, tooling and evidence
Managing the health of any population is made possible by transforming data into information, gleaning insights from that information and translating those insights into action.[2] This project was marked by an understanding that the PHM endeavour should be data driven.
It was acknowledged that the days of decision making based on hearsay and fairy-tale were over.
There are a number of different analytical tools that compromise a Population Health Management (PHM) toolkit. These tools can help set and/or confirm priorities. They can be deployed to highlight opportunities for improvement, and they can help identify cohorts, and individuals within those cohorts, with the greatest capacity to benefit (sometimes referred to as impactability).
In terms of the data, the project agreed that a minimum requirement was a linked primary and secondary care data set. In terms of tooling, population segmentation and risk stratification were identified as being essentials. At the end of the segmentation and risk profiling work, time was taken to explore in greater granularity the population characteristics of the complex cohort. These characteristics included age, deprivation, co-morbidities and location. There was a strong emphasis on health inequalities/health inequity. Some of the key questions asked where: How are we currently servicing these people? Is their unmet need? What is the opportunity for improvement?
It was well understood that other data sources were important and other tools desirable. However, a decision was made early not to ‘boil the sea’. A journey of a thousand miles starts with one step and the most important step is the first. Perfect is the enemy of the good.
Don’t forget monitoring and optimisation
As the intervention moves from design through to implementation, monitoring is required in order to ensure that the intervention is being delivered as envisioned and that it is achieving the desired outcomes that were intended. It is therefore vital that the PHM Team are constantly monitoring process and outcomes metrics on a regular basis. Optimisation is the means by which better outcomes are assured. PHM intervention programmes are living organisms. They should evolve and flex in order that they might best meet the personalised – and often changing – needs of patients. Optimisation involves the systematic review of PHM working practices to ensure that the needs, wants and desires of patients and citizens are fully met. The process is dynamic.
Nothing gets done without workforce
The primary purpose of PHM is to identify individuals within an impactable cohort who might benefit from the delivery of transformed services. The central task is to identify individuals who are eligible for enrolment onto an intervention programme. These interventions are delivered by people not PowerPoint and these people – the workforce – need to be expert and qualified. They are multi-disciplinary, and they are drawn from the well of community assets that exist in all Places. This is a lesson from Covid.
The health and care system is currently – and rightly in my view – being asked to implement and adopt PHM as ‘business as usual’. This ask comes at a time when the System is experiencing one of the greatest workforce crises in its history.
All that I describe here in terms of thinking and process will come to nought if there is an absence of a skilled workforce to action. Workforce planning is essential.
Population Health Management – one person at a time
I’ve ‘borrowed’ the above statement from Matthew Swindells[3]. It speaks volumes. When we speak of populations, all roads lead back to the individual.
My colleague, friend, and population health guru Dr Steve Laitner[4] also offers wise counsel here. He states, “Population Health Management is not about the whole population at once, but cohorts of people with similar needs. It is about the whole person within the cohort, all their risks, needs and preferences”.
Never forget that the individual patient/citizen has primacy in all PHM endeavours.
You won’t get it right first time
You just won’t. But you will.
Enjoy the ride. Along the way you will love, live, and learn and you will be part of a story that makes life better for all manner of deserving individuals.
Who wouldn’t sign up for that?
N C Slone
21/02/2022
[1] Martha Sylvia & Ines Maria Vigil – Population Health Analytics. Copyright©2022 by Jones & Bartlett Learning LLC www.jblearning.com
[2] [2] Martha Sylvia & Ines Maria Vigil – Population Health Analytics. Copyright©2022 by Jones & Bartlett Learning LLC www.jblearning.com
[3] https://www.linkedin.com/in/matthew-swindells-mjs-hc/details/experience/
