A step-by-step guide to managing the pandemic of multi-morbidity using population health management has been discussed in a blog for NHS England by Dr Helen Davies, GP clinical lead for community and population health management in Calderdale, part of West Yorkshire Integrated Care Board.
Helen explains that evidence shows that healthcare is best delivered as an integrated care system with person-centred care at its heart. She notes that data indicates how multimorbidity is driving demand and cost, with more than one in four adults in England living with two or more conditions, which leads to common issues such as reduced mobility, chronic pain, shrinking social networks, incapacity to engage with work, and lower mental wellbeing.
“To date, these problems have not been well addressed by services or research,” Helen states, adding that there is a tendency to organise services around single conditions, train doctors in specialties, and focus research on one disease at a time.
To address and help people with multiple conditions, Helen writes that innovative ways of intervening are needed which is why there is a need for a population health management (PHM) approach.
Helen shares her step-by-step guide to PHM.
Step one focuses on prioritisation. Helen says: “Use data analysis or community stories to find priority areas such as unwarranted high cost or high demand, or unmet need or inequality of care.”
The wider the linked system data is, the more informed decision making can be. However, “you need to get on with it using your ‘best available insights’. This can be cross referenced to compare against similar practices and areas, such as fingertips data and Joint Strategic Needs Assessment.
Step two is about identification. This focuses on using data analysis to identify a cohort in a priority area to find the best opportunity to improve the efficiency, equity and quality of care.
“This may include a particular condition(s), or more likely a group of conditions or just “comorbidity” or “complex needs” within a geographic area, a particular demographic (age, ethnicity) or those at risk of a hospital or care home admission,” Helen writes.
Understanding is the focus of step three. Helen highlights the importance of using a wide lens to include the broadest range of available insights, and to include the carers or patients voice to understand their specific cohort.
Helen adds how “seeing it from the patient or citizen side will address wider determinants of health and consider health inequalities. Use this broad view to get a clear picture of the existing resources and services.”
Step four highlights design of the new care model. Helen explains questions to ask such as what the needs of the cohort are; what outcomes you need in order to meet those needs; what activities needed to do to achieve them; and what skills and resources are needed to invest those activities.
Implementation is the focus of step five: the how, who, and what involved in making it happen.
“You need to ensure necessary buy-in from system leadership and stakeholder organisations for the support, co-operation and IG processes to deliver the plan. From the start of the plan, measure the outcomes and outputs including both the patient and care provider feedback,” Helen notes.
Finally, for step six, teams must expand and evaluate. Questions focus on reaching the target group; achieving the intended outcomes; what has worked well and what to improve; any changes needed to make; and how to scale up and share the plan.
Helen adds “involve all relevant stakeholders and the patient or citizen at every stage from information gathering, planning and designing to delivery and evaluation. Make sure to combine best laid plans with pragmatic delivery.”
