Dr Dan Bunstone, GP and clinical director of Warrington Innovation Network, has shared how a population health management approach was undertaken in order to proactively manage hypertensive patients through use of the HealthyYou app.
Warrington Innovation Network PCN used the UCL partners risk stratification tool to identify more than 2,500 people across three categories: where their GP had recorded their blood pressure above a certain threshold, where their last reading was high but had not been optimised yet, and where medication was not optimised for the treatment target.
In the blog, Dan describes how around 1,000 people were recruited onto the HealthyYou app, a remote monitoring solution enabling patients to submit their own blood pressure readings and supporting the creation of an average ‘at home’ blood pressure. Patients who require reviews are then flagged to clinicians.
Using this approach, over 500 patients have been treated to target and a further 200 patients are undoing clinical review, with Dan highlighting that the intervention has “significantly reduced” risk of stroke and heart attack. Other outcomes include reducing the average systolic blood pressure in the cohort by around 12mmHg, and reducing the average ‘Q-Risk3 lifetime’ by around three percent. Dan explains that Q-Risk3 “estimates your risk of getting cardiovascular disease over your lifetime”, with a three percent reduction meaning “30 less cardiovascular events in our first cohort of 1000 over the next three years, with an expected saving of over £400,000 to the wider health and social care economy.”
The project has gone from being implemented at a single surgery to rolled out across the PCN; with the support of the wider ICS, Dan shares that the initiative is set to roll out across the whole of Warrington from April.
Dan goes on to highlight some tips for building a successful business case and securing buy-in; read the blog in full here.
Population health management has taken focus in two London strategies covered by HTN last year; West London NHS’s five-year strategy, available to read here, and North East London’s integrated care strategy here.
We also previously welcomed Hampshire and Isle of Wight ICS at a HTN Now event, to share key learnings and experiences acquired from their population health management journey.
