In recent months we have seen the publication of two important documents, both of which focus on what needs to be done in order to deliver successful health and care integration:
- Stepping up to the place: The key to successful health and care integration
- The Journey to integration: Learning from seven leading localities
Both publications talk to the importance of population-based planning and the power of population segmentation. Segmentation here refers to the use of ‘big data’ that divides populations into distinct groups with different characteristics, for which intervention programmes can be designed.
With patient segmentation different needs can be identified within populations, and delivery models (new care models) can be tailored for homogenous patient groups. More often than not this kind of analysis is also deployed when looking at establishing budgets (e.g. capitated budgets) in support of these new delivery 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 will 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. This population segmentation can 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 data mining skills and intuitive analytical tools. Those tools and skills, together with the competencies to deliver on population segmentation strategies, are available today.
Together, Sollis (Sollis Clarity) and Johns Hopkins HealthCare (ACG® System) provide the analytics and insights to make your segmentation strategy a reality. Together, we are working with other health economies to help them deliver on their population health strategies. For example, NHS Slough CCG and NHS Wandsworth CCG are both using Sollis Clarity and the ACG System for population segmentation and population health analysis. For more information, see Slough CCG’s case study and our Wandsworth CCG PACT case study.
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