Sollis Clarity Health Analytics Additional Data Modules

Data is the Key

One of the keys to successful health and care integration is the availability and free flow of data sets and information, to help understand the totality of the health and care needs of local populations. Data is the key to delivering quality, equity and efficiency.

Place based systems of care, where organisations collaborate to manage available resources, need to understand how health and care resources are currently being delivered and consumed before planning new interventions and new models of care. They must look across the care continuum and consider quality and cost across all care settings. Only then can those charged with delivering improvements better understand the health needs of populations and tailor health services’ resources to the population.

Essential components of any population health strategy are data acquisition, data management, data aggregation and data security. The first task is the creation of a data asset harvested from across the care continuum. Once the data asset is prepared, software analytics — such as that delivered by the Johns Hopkins ACG® System — add additional metrics and analyses. Health analytics — the generation of real insights upon which intervention decisions can be made — follows from this.

Sollis Clarity brings together comprehensive GP records with details of acute hospital care activity. Building on this, the Sollis Clarity Additional Data Modules are key to the delivery of integrated care for the benefit of the whole population.

Community Care

Community care covers a wide range of care professionals, from health visitors and district nurses to specialists focused on particular disease areas, such as COPD, diabetes or cancer.

Community data is increasingly seen as a fundamental part of the population health data set. As commissioners concentrate on the need to move care out of acute settings wherever appropriate, there is a growing focus on community services, alongside primary care. The Sollis Clarity Community Care module can help commissioners and clinicians plan — and deliver on — this journey.

Benefits to Commissioners

  • A more complete, integrated picture of the behaviour of the whole local health economy, enabling a wide range of new analyses and insights. For example, the impact of multimorbidity on community care activities.
  • Define and monitor specific transformation programmes dependent on community care delivery.
  • Relate community care data to other care data to identify patterns of unexplained variation in provision and cost.
  • Gain a deeper understanding of local community care activity, to improve local provider management and ensure it aligns with disease burdens and population health needs.
  • Monitor the use of community services alongside other health and care providers, supporting business-as-usual monitoring as well as transformation programmes.

Benefits to Clinicians

  • Improved case finding, including particular types of community care alongside other filters (for example, higher-risk patients known to community services and in receipt of specific care activities).
  • Identify gaps in care, such as diabetic patients not recently in receipt of diabetic community care.
  • See a more complete view of the care being received by individual patients, to help support improved clinical decision making (by MDTs, for example) and coordinate patient care between services.
  • Clinical staff, including specialist community nurses, may also gain specific insights from the detailed nature of community care activities being delivered to the patient.
  • Improved support to community MDTs, enabling better clinical decision‑making.

Mental Health

Mental health conditions can be captured and in some cases treated in many care settings, not least GP practices and acute hospitals. However, the work of specialist mental health units is key to an understanding of the whole mental health needs of a population. At the same time, particular mental health conditions can be drivers of risk and cost, and with the addition of this module can be fully reflected in patient and population risk scores.

The Sollis Clarity Mental Health module enables commissioners and clinicians to build a comprehensive picture of local of mental health care needs, and its delivery.

Benefits to Commissioners

  • Patient need and resource utilisation reporting, covering primary, acute and the variety of mental health services, helps build understanding of the combined needs of the population, and variation within it.
  • Diagnoses from within mental health service settings help improve the quality of Clarity’s analyses exploring unplanned variation in care.
  • Extend cohort analyses to include a wider range of mental health conditions.
  • Identify other areas for improvement (for example, crisis planning) by tracking links between mental health and acute activity.
  • Identify opportunities to improve or transform local mental health services and monitor the results.
  • Understand the impact of mental health on service utilisation (for example, did-not-attends, longer length of stays).

Benefits to Clinicians

  • Extend case finding to support local care programmes addressing those with mental health needs (for example, find higher risk patients with two or more physical long-term conditions plus recent mental health activity).
  • Support clinical decisions through the understanding of recent physical and mental health support given.
  • Identify gaps in care, such as missed mental health appointments.
  • Provide additional intelligence to inform clinicians’ multidisciplinary meetings (including with mental health professionals), to plan the support for people with complex health care needs.
  • Gain a better clinical understanding of the combined impact of individual patients’ physical and mental health conditions.

Adult Social Care

It is increasingly recognised that the health care and social care systems must function effectively together to support the citizens they serve. Adult social care typically covers a range of services, from home visits, impairment support, reablement services and physical and mental care services. It is important that these services are targeted to meet the right service users and patients.

The Sollis Clarity Adult Social Care module helps commissioners, clinicians and social workers align the overall Health and Social Care provision.

Benefits to Commissioners

  • Explore correlations and unexplained gaps in health and social care provision, by looking at teams who offer related services, for example.
  • Apply additional criteria for cohort segmentation and variation analyses.
  • Monitor and develop pathways which include social care as well as hospital, such as reablement services.
  • Identify opportunities for cost savings through joint management of care, then plan and monitor them.

Benefits to Clinicians

  • Extend case finding to support local care programmes addressing patients with complex combined needs.
  • Support clinical decisions through the understanding of recent social care support given.
  • Identify gaps in individual care or associated care records (for example, lack of planned reablement services; social care support given for a condition not in the clinical record).
  • Improved support to inform clinicians’ multidisciplinary meetings (including with social workers), to plan the support for people with complex health and social care needs.