Five Steps to Population Health Management

Population Health Management

Population health management helps health and care professionals identify and quantify the drivers and outcomes for addressing local population health, and it has a significant role in commissioning for value.

Sollis believes patient-centred care strategies based on the needs of local populations provide the key to better population health management. A range of tools and processes provide the evidence base and the insights (those lightbulb moments) to inform service transformation and monitor value through outcomes.

A Population Health Management Strategy

Below are what we believe are five key steps in establishing a population health management strategy, and our role in helping commissioners or Accountable Care Systems to deliver on it.

1. Define the target population and assess its needs

The first step to improving population health management is to analyse the morbidity burden of the local population. If you don’t know the current health status of your local populations, it’s impossible to know what services need to be in place, and where, to cater to those populations.

The NHS Atlas of Variation is a good starting point for understanding the health economies of local populations in a national context and relative to their demographic peers. For example, it may highlight an above average rate of A&E admissions for children with asthma. Such indicative data warrants further investigation before deciding whether a new programme is required to target those patients.

Population healthcare focuses on populations with a common need, which might relate to a condition, such as diabetes, a symptom or a characteristic, such as frailty, in order to maximise value for those populations. It doesn’t focus on institutions, specialties or technologies.

Risk stratification and population profiling tools, such as Sollis Clarity Health Analytics and the Johns Hopkins Adjusted Clinical Groups® (ACG®) System, provide more detailed analyses and help commissioners validate variations between populations and to really understand what is happening right now in the local population. Using the example above, identifying the GP practices of the patients presenting at A&E, and looking at their morbidity burden, provides a solid evidence base on which commissioning and service transformation decisions can be made. A CCG-wide programme may not provide the best value if the outliers are centred on very few GP practices, or if they have complex conditions due to multimorbidity.

2. Set, measure and monitor outcomes

Commissioning based on cost and volume focuses on individual organisations treating diseases/conditions, working separately from other healthcare providers also treating the patient. This can lead to a fragmented approach to care delivery with no overall responsibility for patient outcomes.

Outcomes based commissioning promotes integrated care, centred on the patient, in order to provide better health outcomes and value for money. Outcomes based commissioning relies on budgeting for the care of particular populations. Providers are rewarded for working together to deliver services that meet the outcomes requirements for these populations.

To set budgets and measure outcomes, commissioners need to understand the current patient populations (through population profiling), risk stratify patients into cohorts, set their budgets taking into consideration the morbidity burden of their populations (using casemix), and set equitable outcomes targets and budgets based on those findings.

Measuring outcomes is one method of assessing the value of changes to the co-ordination, integration and delivery of healthcare. Trend data for activity, costs and patient risk profiles, along with population profiling, can provide a valuable indication of the effectiveness of treatment patterns and service provision.

Sollis Clarity Health Analytics provides various methods of monitoring outcomes, from trend reporting to a clinical code listener that identifies patients with diagnoses indicating specific conditions, such as dementia or frailty.

3. Develop the IT infrastructure for data analytics and reporting

Data analytics must be delivered for whole populations, segmented (risk-profiled) populations and at an individual patient level. Therefore the technology platform on which commissioning business intelligence is based must be proven and scalable, particularly where these solutions are centred on large scale data acquisition, processing and management — the transactional aspects of commissioning.

Data analytics and reporting must also serve commissioners at the local level. Technology and service offerings must therefore be tailorable, and when deployed as close to the patient as possible enable clinicians to take decisions that help to deliver on the transformation aspects of commissioning. Software and services that serve population health management should be flexible enough to allow local experts bring their experience and local knowledge to bear.

4. Build an information exchange for data storage

Integrated care requires integrated data. Commissioners and clinicians must have access to patient data and, be it pseudonymised, anonymised or in the clear, analyse it and turn it into meaningful action. They need the confidence to be able to make informed decisions based on the data at their disposal. When NHS organisations have control of their data, it is open to local interrogation and analysis requirements. Of course, flexible, information governance compliant security is a prerequisite for any such data warehousing.

Because Sollis has been working with NHS commissioning data since 1994, we have the experience needed to offer innovative solutions that meet the data management requirements of commissioners and accountable care organisations. Our population health analytics solutions include a scalable data warehouse suitable for use in small NHS Trusts up to multi-organisation, hosted environments. While it houses a wide array of NHS datasets, it is by no means limited to national data flows and can capture, store and make available anything from direct access radiology activity to specialist theatre records.

The Sollis data warehouse is the ideal mechanism for providing an integrated understanding of all of the care a patient receives, from each and every provider. It is thus an ideal tool to assist in case management and care planning, for individuals and groups of patients.

5. Enable commissioners and providers to share data from myriad datasets

As the NHS moves toward care models where it incentivises collaboration — focusing on population wellness, as opposed to just fixing illness, and where we target outcomes for health and wellness that matter to whole populations — we need to make transparent as much as possible of the existing health and social care data that is currently at our disposal. Information, data sharing and business analytics are critical to support a successful population health management strategy.

Because Sollis Clarity Health Analytics secures data from across the local health and social care system, the intelligence it delivers provides insights into activity across the health economy. A sound knowledge of the morbidity patterns of different populations can help evaluate the efficiency of different healthcare providers and help to set capitation payments equitably.

The measurement of outcomes across the care continuum requires transparent measurement and monitoring tied to incentives. With data transparency comes data sharing and the need to find a balance between privacy and the need to share and access data across health and social care providers. Opening up patient data for analysis by commissioners and providers can reap major health benefits. However, in a world of complex health needs, personalised care and capitated budget models, or in a world of outcomes based commissioning, where the patient’s views on their care can affect the income that a provider receives, individuals will become more engaged in the management of their own care. It is possible they will want more of a say — and in more detail — about how the information about that care is secured and managed.

Sollis is an NHS England approved third-party data processor, supplying population health management and risk stratification services to NHS organisations, meaning that we have rigorous processes in place for dealing with patient identifiable data. Sollis data processing complies fully with NHS England’s Information Governance policies and is in accordance with the Data Protection Act 1998. The Secretary of State for Health has approved Sollis’ application to access confidential patient information without consent.

See it in action

If you’d like to see how Sollis Clarity Health Analytics and the ACG System can provide the health analytics and insights to inform your population health strategy, you can ask us for a demo via WebEx or in person.

Understanding Population Health White Paper
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