NHS England (NHSE) has shared a new case study about how a Population Health Management (PHM) approach was able to help a primary care network offer extra support for a high-risk patient group with heart failure and social isolation.
The Titan Primary Care Network (PCN), which is part of the Bedfordshire, Luton and Milton Keynes Integrated Care System (ICS), was able to help 37 people in Bedfordshire with confirmed or suspected heart failure to ‘get extra medication reviews, assessment of their social support and assess any issues with isolation or housing’.
A team identified those who were at risk of deteriorating due to social vulnerability by using a population health management approach – called on the Population Health Management (PHM) Development programme project – which has now been offered across the country. This included addressing ‘the wider determinants affecting their health’, improving their access to existing health services, optimising medication, and improving ‘activation’ and health literacy.
The PCN wished to provide more personalised help to ‘improve their health and wellbeing and reduce health inequalities’, which led to a new team forming, which was comprised of GPs, data analysts, social prescribers, clinical pharmacists, care co-ordinators and a community heart failure nurse.
Work undertaken as part of the project involved analysts linking general practice and acute datasets together to ‘understand the impact of social isolation on people with heart failure’ and hone in on those in the highest risk categories who ‘would benefit the most from a more intensive help’.
The GPs then invited the cohort to take part in the project, which saw them receive a combination of phone calls, home visits and medicines reviews with the social prescriber, heart failure nurse and pharmacist. Social support arrangements and circumstances were also assessed, with patients encouraged to ‘self-manage their condition where appropriate’ or, where they needed ongoing support, placed in the wider multi-disciplinary team group.
Results from the work so far, meanwhile, include that by using the PHM approach, the team have identified 116 people, with 41 invited to take part, and 37 people ‘deemed suitable to benefit’.
NHSE says that the team encountered several challenges during the project, including:
- Workforce – as a small PCN, the ‘scale and pace’ of work was impacted by priorities e.g COVID vaccinations.
- Coding from primary and secondary care.
- During the pandemic, patients were not always been able to ‘take up a virtual offer’ and teams ‘did not have the capacity to see everyone’, with the highest risk patients prioritised first.
Learnings shared through case study include that NHSE says the PCN has ‘recognised the importance of the care coordinator role’ and of having a ‘dedicated team focused on the intervention’. This has led to a decision to ‘redeploy a member of staff into the care coordinator role while waiting to recruit permanently’.
Other learning outcomes include understanding that while having access to linked data is ‘vital’, support for staff at ‘each level of the system’ to ‘understand, interpret and operationalise the insights’ is just as important.
PHM analytics will be a key part of the intelligence available to the ICS going forward, with close links between care providers and local community groups considered to have been proved ‘invaluable’ in making the insights actionable.
Using learning from the pilot cohort, the ICS plans to ‘use data to proactively look for patients who are socially vulnerable’ and who ‘have recurrent admissions for heart failure’ but are not engaging with primary care.
The full case study is available to read through NHSE, here.
