Hertfordshire and West Essex Sustainability and Transformation Partnership POPULATION HEALTH MANAGEMENT PROF JIM MCMANUS CLINICAL STRATEGY PLANNING WORKSHOP SEPTEMBER 7 TH 2018 APPENDIX A
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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