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 new care models.
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.
An example strategy for addressing population health management could involve the following steps:
- Understand the health status of the local population
- Identify potential areas for change
- Monitor the effects of change through outcomes
Understand the health status of the local population
The first step to improving population health management is to analyse the morbidity burden of the local population. The NHS Atlas of Variations 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 children with asthma.
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.
Population profiling tools, such as Sollis Clarity and the ACG System, provide more detailed analyses and help commissioners validate variations between populations and to really understand what is happening 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. An STP- or CCG-wide programme may not provide the best value if the outliers are centred on very few GP practices, or that they have complex conditions due to multimorbidity.
Identify potential areas for change
Population profiling is a process that leads to a better understanding of the current and future health needs of whole populations, and helps to identify opportunities for service transformation. By comparing morbidity patterns across local populations, such as GP practices or geographical areas, and taking differences in case-mix into account, those building and evaluating new care models gain insights into the effects of local healthcare methods. This can then help to inform decisions about the nature and setting of services that need to be provided.
Population segmentation and risk stratification also play their parts in developing co-ordinated care strategies and supporting population health management. Population segmentation categorises populations according to health status. This helps you to understand the health care needs and priorities of defined populations for which outcomes based approaches might be beneficial, for example. Risk stratification has a significant role in changing methods of resource allocation. Resource allocation based on risk profiled populations helps accountable care systems to target resources at populations most in need.
The ACG System used by Sollis Clarity is a person-focused case-mix system for identifying and measuring the multidimensional nature of patients’ health. By capturing and describing the morbidity burden of individuals, population segments and whole populations, it enables clinicians to explore integrated care programmes that look to address the multiple care needs of the person rather than focusing on their individual conditions.
Monitor the effects of change through outcomes
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 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.
A population health management strategy
Are you looking to implement a population health management strategy? Read our Five Steps to Population Health Management article.
See it in action
If you’d like to see how Sollis Clarity can provide the health analytics and insights to inform your population health management strategy, you can ask us for a demo.