Hertfordshire and West Essex

Sustainability and Transformation Partnership

POPULATION HEALTH

MANAGEMENT

JIM MCMANUS

HEALTH AND WELLBEING BOARD, MARCH 2019

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Commissioning and Delivery – The Mechanics

A common purpose

There are five overall aims of Population Health Management:

• Improve the health and well-being of the population

• Enhance experience of care and support

• Reduce per capita cost of care and improve productivity

• Increase the well-being and engagement of the workforce

• Address health and care inequalities

Why is it important?

The Triple Aim - What

Better care for

Individuals

Better health for

PopulationsLower Cost

Wider

determinants of

health

Person

centred

care

Social

movement

for health

A framework for improving health and

care at scale1. Achieving a best start for children and

families.

2. Achieving a fully engaged scenario withcommunities and people mobilised forimproving their health and wellbeing.

3. Address the unwarranted variation inmanagement of risk factors and carepathways.

4. Proactively meeting demand byidentifying and supporting individualsand families with complex needs.

5. Improving the wider determinants ofhealth by embedding health in allpolicies including housing, employment,planning and licensing, transport, andadvocating for national healthy publicpolicies.

This work stream, whilst delivering specific programmes, is also linked to all other portfolios

of the ICS

A common definition

Population Health is an approach aimed at improving the health 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 improves population health by data driven planning and

delivery of proactive 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.

There are 3 core capabilities for Population Health Management

What are the basic building blocks that

must be in place?

• Organisational Factors - defined

population, shared leadership &

decision making structure

• Digitalised care providers and

common health and care record

• Integrated data architecture and

single version of the truth

• Information Governance that

ensures data is shared safely, securely

and legally

Opportunities to improve care quality,

efficiency and equity

• Supporting capabilities such as

advanced analytical tools and

software and system wide multi-

disciplinary analytical teams,

supplemented by specialist skills

• Analyses - to understand health and

wellbeing needs of the population,

opportunities to improve care, and

manage risk

• Interpretation of evidence to identify

targeted, high impact interventions

Care models focusing on proactive

interventions to prevent illness, reduce

the risk of hospitalisation and address

inequalities

• Care model design - delivery of

integrated personalised care and

interventions tailored to population

needs

• Community well-being - asset based

approach, social prescribing and

social value projects

• Workforce development - upskilling

teams, realigning and creating new

roles

Infrastructure Intelligence Interventions

Neighbourhood

~50k

• Multi-disciplinary teams using real-time risk stratification to flag

interventions for populations and individuals.

• Using person level data for case identification and management

and to optimise how people are directed through their pathway of

care.

Place

~250-500k

• In-depth segmentation, risk stratification, and actuarial analysis to

identify opportunities to redesign care and develop proactive

interventions to prevent illness and reduce hospitalisation.

• Integrated Care Providers building capability to track people and

combine real-time workforce, bed capacity and activity data to identify

productivity opportunities

System

1+m

• Population Health Strategy based on whole population health and care

needs assessment and gap analysis to identify overall priorities.

• Whole population profiling and system modelling to understand likely

future health outcomes and where system wide action may be

effective.

• Commissioning of outcome based care.

Individual

• Individual having access to and being able to amend their own care

record enabling self care.

• Health and care professionals across settings having access to an

individual’s care record to support personalised care, PHBs and

targeted prevention.

Embedding population health management across all tiers

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.

Neighbourhood

~50k

• VCFS organisations and community assets mobilised to support

neighbourhood teams

• Wider public sector services aligned (e.g housing, employment

support)

• Organising public health and preventative services

Place

~250-500k

• Working with district councils to address

• Local place based policies on housing, transport, air quality

• Working with housing associations

• Engaging with schools and colleges

• Partnering with local businesses on work and health

• Place based analysis of needs and determinants of health

System

1+m

• Embedding health and wellbeing into the wider public services reform

agenda (including Govt Depts e.g DWP)

• Shared programme of work with Enterprise Partnerships

• ICS-wide Health and Wellbeing Board to champion population health

• System-wide JSNA on HWB and determinants of health

• Ensuring resource allocation for prevention and improving wider

determinants

Individual

• Health and care professionals across are able to have strengths based

conversations with individuals

• They are able to identify social factors and their impact on individual’s health

• Frontline care providers become better advocates for socio economic and

environmental determinants (Seeds) of health and wellbeing

Embedding social economic and environmental determinants across

all tiers of the system

• At strategic and operational level this needs to

identify actions for different agencies, from

the NHS to local authorities, third sector and

others. How well we understand our

competencies, the fact we ALL have a role –

and there are STRONG clinical components to

this for EVERY clinician, and who is best placed

to do what will determine whether this

approach ever gets off the ground

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System Approach

13

3. Reducing the need and spend curve:

Preventing avoidable spend in public service

Highest cost.

Reduce and delay

Need ehere

Reduce or delay need here

Intervene here before need

escalates

Volume of

spend

Severity of need

Existing curve

3. The Aim from reducing the spend curve

Volume of

spend and

cost

Severity

Existing curve

The Achievable

curve?

Healthy Diagnosed

Condition

In treatment

Complex

Place based, social

prescribing,

social marketingPathway

Wrap round

care

co-ordinated

approach

Population Health Management• Proactive application of strategies and interventions to

defined groups of individuals, to support prevention and

chronic disease management - whilst managing costs

• This includes –

assessing population across the continuum of care

stratification and modelling of defined ‘at risk’

populations

development of management plans depending on each

groups needs

surveillance

performance management etc

• STRATIFYING – By need/risk/severity

• SEGMENTING – By lifecourse stage

• IMPACTABILITY – What will be the outcome of

doing this and WHERE -primary care,

secondary care,social care, community

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Generally well

Long term

conditions /

Long term

needs

Complexity of

LTC(s)

and/or disability

Low

riskHigh risk Low risk High risk Low risk High risk

SEGMENT

Children and

Young People

• Neonates

• Infants

• Toddlers

• Children

• Adolescents

STRATUM STRATUM STRATUM

SEGMENT

Working Age

Adults

• Young

• Middle aged

• Older working

age

SEGMENT

Older People

• 65-80

• 80-90

• 90+16/04/19 Dr Steve Laitner

With thanks to Steve

Laitner for this slide

Stratification• People who are generally fit and well need access to high quality

and effective primary prevention interventions in order to prevent disease and stay well.

For example, childcare, education, family support, physical activity, employment, housing, social interactions, diet, avoiding smoking and drugs, safe alcohol consumption

• People with long term conditions need to be identified early to help them stay well and prevent future complications.

For example through community based help, personalised care planning, self-management support, medicine management and secondary prevention services.

• People with complex comorbidities need personalised care to maintain their quality of life.

Population Health Management

Case

Management

Specialist Disease Management

Supported Self Care

Population-wide prevention

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Robert

Wood

Johnson

Foundation,

2014

Requires a collaborative strategy

between leaders in healthcare,

politics, charity, education, and

business

True Population

Health

Management

Children and Young

People

Working Age Adults

Older People

Population health cube

© 2017 National Association of Primary Care 16/04/19 Dr Steve Laitner

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Population segmentation reveals vast differences in resource

consumption by difference groups of population

Source: Kent Integrated Dataset, Carnall Farrar analysis *NOTE: Excludes Children’s Social Care 8

Generally well/good wellbeingLong term condition(s)/social

needs

Complexity of LTC(s)/ social

need and/or with disability

Children and

young people*

Working age

adults

Older people

- -Population,

Thousands

Spend, £

Millions

0.3 1.9

Spend per head, £

1.7 10.3

0.1 0.31.0 0.9

17.6 30.2

4.3 10.5

8.6 3.6

16.7 5.8

0.7 1.3

7,507

5,948

4,000940

1,721

2,445

425

348

1,824

50k population in Kent and Medway

INCREMENTAL APRPOACH

Focus on gains which can be made easily and systematically, identify areas where most “health gain” can be made

This is NOT about saying “it’s all about wider determinants” or “well we have to do primary prevention” IT IS NOT

There are cohorts of people already morbid, in the system, where evidence shows this approach can produce benefits in short, medium AND long term

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• Worth noting that PHM is not new.

– Eg Stratifying group populations by risk is something we already do

– Disease management programmes exist for those identified

• What is different now?

– We want to work with partners and develop more co-ordinated approaches to improving population health, reduce costs etc –need to share data to do this

– New STP/ICS geographies – including 30-50k ‘neighbourhoods’

– Technological advances…

Four Core Components

Mindset. Evidence. Culture. Interventions

• Mindset

– Workforce Attitude, Culture and Skills

• Evidence

– Analytics, Informatics and Data – getting the data to help drive decisions and approaches

– Evidence of what is effective

• Culture

– A culture which puts this approach into action every time

• Interventions

– Pathways – being able to pathway people and shifting investments to make it happen

– Interventions – knowing the intervention

Some groundrules• Don’t start with primary prevention, start with

the populations who are already in the

system, and where gains could be made most

quickly and easily

• What can be made “routine”? (eg smoking

cessation as core part of respiratory care)

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Four Critical Success Factors, Many Hurdles Along the Way

Achieve Data Transparency to

Manage Utilization

• Hard to arm physicians with information due to

limited transparency provided by payers

• Difficult to link and reconcile disparate data sets

using data warehouse solutions

• Internal clinical and financial systems constrains

visibility to utilization inside organization

Prioritize Patients at Highest

Risk of Poor Cost and Quality Outcomes

• Predictive analytics required to forecast outcomes

with accuracy not a core competency of EMR,

financial system vendors, or providers

• Lack of robust benchmarks prevents identification

of actionable opportunities based upon gap to

benchmark

• Limited visibility into psycho social factors

Focus Interventions on Highest

Prioritized Opportunities

• Lack of integration between analytical and

workflow tools prevents effective execution

• Difficult to quickly identify and engage the

appropriate resources for each intervention

• Limited ability to bring together timely clinical

and financial risk data for clinicians at the point

of care

Measure Impact of Interventions and

Continuously Improve

• Difficulty linking cost and utilization data

hinders ability to track and trend PMPM costs

• Data complexity prevents routine analyses with

frequency required for course correction and

continuous improvement

• Difficulty connecting productivity of care

managers to outcomes and return on

investment

Clinic

ian

Com

missi

oner

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