Hertfordshire and West Essex

Sustainability and Transformation Partnership

POPULATION HEALTH

MANAGEMENT

PROF JIM MCMANUS

CLINICAL STRATEGY PLANNING WORKSHOP

SEPTEMBER 7TH 2018

APPENDIX A

Hertfordshire and West Essex

Sustainability and Transformation Partnership

Acknowledgements

• Sue Matthews and Linda Mercy (HCC Public

Health)

• Dr Steve Laitner

• Public Health England

• Association of Directors of Public Health

• The King’s Fund

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Commissioning and Delivery – The Mechanics

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Commissioning and Delivery – The Mechanics

The Triple Aim - What

Better care for

Individuals

Better health for

PopulationsLower Cost

Six Verbs – One Adjective• Segment –

• Stratify –

• Analyse –

• Intervene –

• Iterate -

• Monitor –SYSTEMATIC –

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FOCUS – THIS IS NOT

ABOUT WIDER

DETERMINANTS, WE

HAVE 800,000 PEOPLE

ALREADY ILL WHO

COULD BENEFIT FROM

A SYSTEMATIC

APPROACH TO KEEP

THEM AS HEALTHY AS

POSSIBLE

Six Verbs – One Adjective• Segment – by health status

• Stratify – by age

• Analyse – by population, segment and stratum

• Intervene – tailored and pathwayed

• Monitor – outcomes and impact

• Iterate – with increasing sophistication and making it second nature

• SYSTEMATIC – at all stages

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This will only happen if we have the

right...• Culture & Mindset

– Walk before we can run – incremental approach!

• Leadership

• Systems

– Informatics

– Pathways

– Quality Improvement

• Interventions

– Clinical, social and preventive portfolios

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Achieving Success

Making the

“Triple Aim”

Possible - How

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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Population Health

‘The health outcomes of a group of individuals, including the distribution of such outcomes within the group’ (Kindig and Stoddart)

Influences include healthcare, but more importantly lifestyle, local environment, wider determinants of health etc To achieve a population health model we need agencies at all levels to work together – population health is everyone’s business

The Population Health ‘opportunity’ is to establish new models that address health, care and wider determinants

Eg STP Social Prescribing project, Safe and Well, Warmer Homes

Population Healthcarethis is NOT the same as Public Health or Population Health, it’s one aspect

• Maximising Population Health outcomes through healthcare

• Population Healthcare has been defined by Public Health England as healthcare in which:

• “The aim of population healthcare is to maximise value and equity by focusing not on institutions, specialties or technologies, but on populations defined by a common symptom, condition or characteristic, such as breathlessness, arthritis, or multiple morbidity.”

• Eg STP 100 day challenge work for palpitations, RightCareprogramme etc

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

Reducing the need and spend curve: Preventing

avoidable spend in public service

Highest cost.

Reduce and delay

Need here

Reduce or delay need here

Intervene here before need

escalates

Volume of

spend

Severity of need

Existing curve

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

Our focus for this session is going to

be on Population Health

Management...

This is NOT about wider determinats

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Definition

‘Population Health Management improves population health by data driven planning and delivery of care to achieve maximum impact. It includes segmentation, stratification and impactability 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.’

Data informed planning to improve health outcomes by ensuring the Right Care to the Right People at the Right Time and Place.

• 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+05/10/18 Dr Steve Laitner

With thanks to Steve

Laitner for this slide

Population Health Management

Case

Management

Specialist Disease Management

Supported Self Care

Population-wide prevention

Children and Young

People

Working Age Adults

Older People

Population health cube

© 2017 National Association of Primary Care 05/10/18 Dr Steve Laitner

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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HOW DO WE GET THERE?

1. COMPONENTS

2. COMPETENCIES

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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

THE CORE COMPETENCIES OF

POPULATION HEALTH MANAGEMENT

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Grid on your tables

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)

• Focus – this is NOT About wider determinants. If we were Tesco we would realise we know all these people already.

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