POPULATION HEALTH MANAGEMENT An ICS approach to Population Health Management
PURPOSE OF THIS PRESENTATION? To understand what is Population Health Management To understand why it is important? To understand the systems current position To understand the next proposed steps
OUR REMIT 400,000 300,000 200,000 100,000 South Mid City Notts Notts
WIDE VARIATION IN HEALTH ACROSS THE ICS Across ICS 79.0 years Across ICS 82.4 years Nottingham City 77.0 years Nottingham City 81.1 years Mid Notts 78.5 years Mid Notts 81.9 years South Notts 80.7 years South Notts 83.4 years An average baby boy born in Nottingham City can expect to die 3.7 years younger than one born in South Nottingham. For females, the difference is 2.3 years. Life expectancy differences by ward approach 10 years
POPULATION HEALTH Population Health is an approach aimed at improving the health and care of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partner agencies.
POPULATION HEALTH MANAGEMENT Population Health Management improves population health by data driven planning and delivery of care to achieve maximum impact. It includes segmentation, stratification and impactabilty modelling to identify local ‘at risk’ cohorts - and, in turn, designing and targeting interventions to prevent ill-health and to improve care and support for people with ongoing health conditions and reducing unwarranted variations in outcomes.
WHAT IS POPULATION SEGMENT AND TARGETTED IMPACTABLE HEALTH STRATIFICATION INTERVENTIONS MANAGEMENT? Modelling to identify local Targetting interventions to "at risk cohorts" achieve maximum benefit Population Health Management, is the INTEGRATE HEALTH AND REDUCE UNWARRANTED CARE VARIATION approach in which data is used to understand the needs of the population, Improve care and support for Identify variations in enabling focus and resources to be people with ongoing health outcomes/health inequalitites tailored to areas where the impact can conditions have maximum impact”
PHM LOOKS BEYOND THE HEALTH SYSTEM TO CONSIDER WIDER DETERMINANTS OF HEALTH
INFRASTRUCTURE TO SUCCEED
EMBEDDING PHM WITHIN A SYSTEM More timely joined up data flows and automated analyses will offer insight to enable more responsive anticipatory care, but it will be crucial that systems look to release and streamline capacity and capability to more effectively support care coordination and delivery.
Limitations to this approach • Has minimal impact on small percentage of the High population. Needs OUR Top 2%-20%t • Focuses on those presenting at ED with a Ongoing care needs, PREVIOUS complex need identified. disease management • No proactive or sustained healthcare APPROACH • Limited or no data usage for Mental Health, Social Relatively Healthy/ TO PHM Health Promotion Care, Voluntary • No review of spend Vs Outcomes Relatively Healthy/Health Promotion • No Consideration of Social economic factors
IDENTIFYING VARIATION DIABETES PATIENT A DIABETES PATIENT B Cost to the system £3600 Cost to the system £23,600
OUR SYSTEM VARIATION IN USE OF REVIEW AND VARIATION IN PATIENT RESOURCES AND CITIZEN OUTCOMES FINDINGS 1/2 Varying integrated care (MDT) No standardised ‘offers’ giving rise to approach integrated teams inequitable outcomes across the (MDT’s) With inconsistent skill system mix and allocation of staffing resources The system reviewed itself against the national PHM maturity matrix, with the following findings shared with the PHM VARIATION IN RISK LIMITED FOCUS ON Co-ordination group. STRATIFICATION PREVENTION AND APPROACH UPSTREAM HEALTH AND CARE MANAGEMENT Variation in how patients and citizens are identified for care Services focussing on reactive and support, with various focus, management of health and care, sometimes not targeted in the with limited proactive health or right areas. self- care
OUR SYSTEM REVIEW AND INCOMPATIBLE SYSTEMS FINANCIAL VARIATION DATA/INFORMATION FINDINGS 2/2 EXCHANGE Various data sources EMIS, Funding integration differs SystemOne, Rio etc unable to across stakeholder organisations inform a full system flow with varying priorities and Statutory requirement The system reviewed itself against the national PHM maturity matrix, with the following findings shared with the PHM LIMITED SYSTEM Co-ordination group. OVERSIGHT Operational MDT delivery differs across the footprint with no robust monitoring, governance or auditable processes
A NEW APPROACH
Develop ICS PHM 6 STEP PLAN – System Outcomes Develop PHM AS A PLANNING PROCESS metrics and Establish top level segments, measures goals and priority areas e.g diabetes. • Adapted from the national PHM flat pack Develop Establish the local goals e.g. Reduce • Based on the 3I's (Infrastructure to succeed) population amputation rates, number of people • Principles of Bridges to Health developing diabetes segments Identify Establish needs in priority areas e.g. Chinese & priority Asian diets, Pre-diabetes, Deprivation & obesity cohorts Establish the set of interventions that can meet those goals Identify Establish the micro-segments they are effective for e.g. Impactable Metformin for T2 diabetes with eGFR > 30 Interventions Establish the potential impact (mental/physical health, empowerment, cost, etc) of interventions Establish how to implement and measure the impact of Implementation chosen intervention Segmented KPIs (age, gender, ethnic, language, deprivation, healthy vs LTC) Include service user experience, Infrastructure Intelligence Interventions
Develop ICS System Outcomes Increase in Reduction in Reduction in Increase in life premature infant mortality healthy life expectancy mortality expectancy Increase in life Reduction in Increase in Increase the number of expectancy at birth people who have the ICS OUTCOMES potential years school readiness support to self care and in lower deprivation of life lost self manage and improve quintiles their health and wellbeing 05 Reduction in Narrow the gap in the Increase in early Reduction in illness smoking onset of multiple identification and and disease morbidities between the prevalence at time early diagnosis poorest and wealthiest prevalence of delivery sections of the population Develop ICS System Outcomes
Macro (ICS) Micro (PCN/GP) Meso (ICP) Develop metrics and measures Delivering integrated care for individual service Delivering integrated care across full Delivering integrated care for a particular users and their carer through care co-ordination, spectrum of services to the population care group of people with the same disease care planning or condition Diabetes Measures Personalised Measure ICS Ambition Measures ICS Outcome PHM - Increase in life Life expectancy at birth Common Our population expectancy male/female aims… will live long healthier lives Monitor and Healthy life expectancy at Increase in healthy life reduce care birth male/female expectancy gaps Distinguish Reduction in major and minor amputations Increase in life expectancy performance associated with diabetes Inequality in life at birth in lower by ethnicity, expectancy deprivation quintiles language, deprivation Adopt common Reduction in visual loss from Type 2 Smoking scales so diabetes prevalence adults improvement Reduction in illness and Our people and can be adopted Our children have a disease prevalence Co-morbidity rate Reduction in number of people who across all families are good start in life develop Type 2 diabetes providers resilient and have good health and wellbeing Skill our workforce up Smoking to understand, Narrow the gap in the prevalence adults identify, KPIs, onset of multiple impactability, morbidities between the Reduction in percentage of adults classified etc. % of adults classified as poorest and wealthiest overweight or obese as obese or overweight section of the population Admission episodes from alcohol related conditions
SEGMENTATION 1 2 3 4 5 Women and EoL Healthy Disability LTC Children Cancer, Diabetes, Maintaining Learning Maternity and Short period of CVD, Epilepsy, good health and Physical Childrens decline and Mental Health longer services dying (cancer), MSK, SMI, Asthma, COPD, Frailty, organ failure, dementia Neuro Cross cutting segments - Our population will rarely remain static. The movement between segments can be explored via regression analysis technique to enable the system to identify whether specific characteristics can act as a predictor of increasing risk. This enables the system to target where it needs to respond/shift resources. Develop Population Segments
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