CCG News, Secondary Care

Kent and Medway STP benefits from Population Health Management

Kent and Medway STP has used population health management technology from Carnall Farrar to drive savings across the region.

Carnall Farrar have utilised advanced analytics and patient-level datasets to segment the population, focus on specific population cohorts of need and create a new integrated and holistic care offer to those cohorts.

The company said “By leveraging a patient level linked dataset covering 1.8m people our approach segments the population by both conditions and age, understanding the size of the cohort, the service specific and total health and social care spend in each segment. Multivariate regression analysis allows us to determine the drivers of spend in a given geography from which the segmentation grid is designed.”

“This segmentation process allows us to identify which cohorts Kent and Medway should be focusing on, in one case Adults and Older People with Complex Needs, with an average spend of £7,000 per head. A new integrated and holistic care offer is then developed around this population cohort. This model will transform care for vulnerable people, help them to be more independent and keep them out of hospital, unless absolutely necessary.”

With demand rising at 2.5-5% per year across Kent and Medway the approach is expected to reduce A&E attendances by 15%, emergency admissions by 15%, outpatient appointments by 11% and elective admissions by 19%.

Carnall Farrar provided a common and consistent analytical approach and structure for clinicians and commissioners and providers to develop their local care plans at level of 38 primary care homes/ clusters/ localities/ neighbourhoods, 8 CCGs and one STP. The cost to each was shared, making it possible to access skills and capabilities at far lower cost than normally would be the case. The approach also enabled the effective engagement of 18 organisations and more than 100 people to shape the work.

The company said “To identify unwarranted variation, our tool provides the ability to identify and interrogate variation down to GP practice within pattern of care for defined segments of the population. As an example, we can specifically look at the variation in the non-elective admissions of patients who are 70+ with 3+ LTCs and see that there is a 30% opportunity if all GP practices were able to meet the top quartile.”