Understanding population health management
Population Health Management involves a systematic approach to facilitate effective collaboration among healthcare teams in comprehending the current health status and care requirements of local communities.
Additionally, it entails utilising predictive modelling and data analysis to anticipate the future healthcare needs of the population.
The idea is to design health and care provision around the needs of patients in order to:
- Enhance engagement with proactive patients and citizens in the co-creation, administration, and provision of their personal healthcare services
- Focusing efforts on bridging the financial shortfall in the healthcare and social welfare sector through proactive measures that involve eliminating redundancies and directing investments towards preventive measures
- Maximising the use of informatics solutions to guide targeted care interventions to areas of greatest need, and to enhance collaboration among healthcare professionals
The dynamics of our healthcare demands are undergoing a transformation as a result of the evolving lifestyles that we all lead.
These habits culminate in a heightened susceptibility to preventable ailments that subsequently impact our overall wellbeing.
Additionally, we are experiencing an aging population with a rising number of chronic conditions, such as asthma, diabetes, and heart disease.
This, in turn, has resulted in an increase in the gap of health inequality.
PHM and health inequalities
Population Health Management (PHM) is a strategic approach that emphasises the broader factors that influence health outcomes.
It recognises that only a minor fraction of a person’s health status attributes to the quality of healthcare they receive.
Instead, the social and economic conditions, environment, and lifestyle factors play a pivotal role.
Moreover, it values the contribution of local communities and individuals in fostering health and well-being.
To this end, healthcare systems are leveraging data to devise innovative models of care that are proactive and optimise the collective resources of the community.
PHM is a collaborative effort that brings together various entities within the healthcare and public sectors, including local councils, educational institutions, fire departments, social service organisations, housing associations, and law enforcement agencies.
Each of these sectors is integral to the successful resolution of interconnected health and wellness challenges affecting individuals and communities alike.
East Basildon and health inequalities
East Basildon is an area in the county of Essex that experiences high levels of deprivation in many aspects of the community.
Basildon is ranked 136th nationally and 5th within Essex for overall deprivation.
The district is ranked 2nd within Essex for Rank of Extent which indicates the proportion of people living in seriously deprived areas. Basildon is also ranked 2nd for both Income and Employment deprivation.Basildon District Profile
We are working in conjunction with NHS Mid and South Essex Integrated Care Board to tackle health inequalities in the local area.
Our PCN is working closely with Motivated Minds to help those in the community looking to better their mental health.
PHM during the COVID-19 pandemic
The ongoing COVID-19 pandemic has served to underscore the established correlation between health disparities, ethnicity, and socio-economic disadvantage.
To address these issues, integrated care systems, in collaboration with local authorities and voluntary organizations, have implemented Population Health Management (PHM) to detect individuals requiring additional support and those with intricate health requirements in their communities.
This enables targeted efforts aimed at safeguarding specific populations in the community.
This can be achieved through bespoke care models, expert public health guidance, widespread testing, and vaccination initiatives.
The role of the Primary Care Network and PHM
In order to effectively transition to commissioning for outcomes, it is imperative to segment the population into manageable cohorts.
This supports transformational shifts while remaining sufficiently granular to enable rigorous testing of the approach.
By opting to target a specific population segment, the possibility arises for consolidation of service components.
As a result, the development of outcomes tailored to that segment becomes more effective.
This allows PCNs to collaborate with a network of providers in a manner that entails shared accountability for delivery.
A key principle of holistic care is the comprehensive consideration of an individual’s multifaceted requirements, including their physical, mental, and social needs for optimal health and well-being.
The ultimate objective is to transition towards a system that focuses on effective healthcare integration and outcomes.
By carefully selecting a segment, the approach can be effectively implemented and rigorously tested for optimal outcomes.
Importance of integrated care systems
As healthcare systems strive to establish unified care systems, the significance of Population Health Management (PHM) is steadily increasing.
Therefore, PHM will play a pivotal role in facilitating collaboration amongst these systems to enhance the wellbeing of the population.
Per the guidelines laid out in the NHS Long Term Plan, local NHS organisations shall prioritise population health.
The plan will also look to cultivate productive collaborations with local authority-funded services via integrated care systems.
Consequently, PHM serves as the fundamental cornerstone for the development of comprehensive care systems.
As a result, this empowers regional health and care collaborators to furnish a central proposition for the community.
This offers personalised care in proximity to their residences.
The help of social prescribing and self-referral
Social prescribing has been implemented into the primary care network to give relief and assistance to GPs.
Social prescribing is a unique approach whereby GPs, link workers, nurses and other health and care professionals refer individuals to various, third-party local services that cater to their non-clinical needs.
All in all, self-referring has become a better way for patients to get seen by the right NHS service.
As a result, this method caters and relates to a patient’s needs and requirements.