Integrated Care Systems and the Importance of Population Segmentation

Accountable Care Systems have been re-branded as Integrated Care Systems.

Integrated health and social care is dead;
long live integrated health and social care.

Whatever the nomenclature, the vision remains the same: to fashion a different way of working, one that emphasizes place-based care, populations and systems.

When focusing on population health systems we should never lose sight of the fact that the starting point should be the acquisition of knowledge and insight, and that the quest for knowledge starts with an understanding of the needs, wants and desires of the population to be served. Our long-standing relationship with the NHS tells us that insights are derived from data and health analytics expertise.

For those working with population-based planning for healthcare, it is important to harness the power of population segmentation. Population segmentation uses multiple health and care data sources to divide populations into distinct groups with different characteristics, for which intervention programmes can be designed.

Population segmentation techniques identify the health and care needs within populations, enabling integrated care systems to tailor new care models to homogeneous patient groups. This type of analysis often supports and informs the budgets for delivering new care models.

Population segmentation is a key component of any population health management strategy and this kind of work lies at the heart of the current NHS Vanguards’ efforts.

Typically, population health strategies work at three levels:

• Whole Population, where integrated services apply across whole populations (areas, groups)
• Sub-population, where integration programmes are targeted at sub-populations, which are defined in terms of a long-term condition or co-morbidities
• High risk population, where integration programmes are focused on individuals deemed at high risk of certain outcomes, such as an unplanned hospitalisation

To-date, in the UK at least, efforts have focused on high-risk populations, with the ‘Avoiding Unplanned Admissions’ Enhanced Service the most obvious and high profile example. More recently, its effectiveness and continued relevance has been brought into question.

It is our contention that given the universally acknowledged and well-documented challenges currently faced by the health and social care system, the focus needs to shift to population strategies centred on whole populations and sub-populations.

The starting point for a whole or sub-population based health strategy is identifying target populations, using population segmentation to provide detailed insights into those populations. Tailoring interventions to specific segments is the best way of ensuring the most effective use of resources.

Successful segmentation strategies are built on linked health and social care data sets, and their successful implementation requires access to expert data mining skills and intuitive analytical tools. Those tools and skills, together with the competencies to deliver on population segmentation strategies, are available today. With our partners, Sollis is working with STPs, CCGs and Primary Care Homes to deliver on their population segmentation strategies.

NHS Slough CCG and NHS Wandsworth CCG are just two organisations to have successfully deployed Sollis analytics to help create new care models that resulted from a population segmentation approach. For more information, see Slough CCG’s case study and our Wandsworth CCG PACT case study.