Preparing for future shocks: Building resilient health systemsHFG Project
Presentation at USAID's Global Health Mini-University on Friday, March 4, 2016.
Preparing for Future Shocks: Building Resilient Health Systems
Kate Greene (HFG), Bob Emrey (USAID/GH/OHS), Jodi Charles (USAID/GH/OHS), Temitayo Ifafore, (USAID/GH/OHS)
After the recent Ebola outbreak, global health experts have turned to resilience frameworks used by other fields such as agriculture and engineering to understand how to build health systems that can withstand shocks, including infectious disease outbreaks, natural disasters, and political conflict. Speakers will first briefly outline each of the five key elements of the Resilience Framework, adapted from the Rockefeller Foundation and presented in a Lancet article in 2015, that can be applied to health systems. Participants will then work in small groups to discuss which health systems interventions should be pursued in response to a one-page description of an unnamed country. Speakers will then reveal what real-world interventions they designed for the country example and answer questions.
Preparing for future shocks: Building resilient health systemsHFG Project
Presentation at USAID's Global Health Mini-University on Friday, March 4, 2016.
Preparing for Future Shocks: Building Resilient Health Systems
Kate Greene (HFG), Bob Emrey (USAID/GH/OHS), Jodi Charles (USAID/GH/OHS), Temitayo Ifafore, (USAID/GH/OHS)
After the recent Ebola outbreak, global health experts have turned to resilience frameworks used by other fields such as agriculture and engineering to understand how to build health systems that can withstand shocks, including infectious disease outbreaks, natural disasters, and political conflict. Speakers will first briefly outline each of the five key elements of the Resilience Framework, adapted from the Rockefeller Foundation and presented in a Lancet article in 2015, that can be applied to health systems. Participants will then work in small groups to discuss which health systems interventions should be pursued in response to a one-page description of an unnamed country. Speakers will then reveal what real-world interventions they designed for the country example and answer questions.
Introduction to Routine Health Information System SlidesSaide OER Africa
Introduction to Routine Health Information System was created for undergraduate and postgraduate health science students to introduce them to the concepts and methods of routine health information systems.
The learning objectives are to help users explain the roles of routine health information systems (RHIS) in health service management; examine strategies used to improve routine health information systems; acquaint with skills to carry out the process of improving RHIS performance; discuss three categories of determinants that influence RHIS.
Social Determinants of Health InequitiesRenzo Guinto
Lecture given during the pre-APRM workshop on Social Determinants of Health and Global Health Equity, September 11, 2012, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur
The course offers an opportunity to develop a holistic understanding of Global health, its functions, and scope. The course attendants will learn the principles of Primary Health Care, the course is expected to help the students to understand and internalize international health and public health transition facilitating the integration of health sector with other sectors.
Dear all
Please go through the slides if you want to know something about "Core competencies for public health informatics".
I think these slides will be useful for you.
Future of Healthcare – Leadership Challenges
Further to several additional expert workshops this year, we are delighted to share an updated global perspective on the future of healthcare. Produced in partnership with Duke Corporate Education (http://www.dukece.com), this adds new insights on the pivotal shifts taking place across the sector plus viewpoints on some of the core implications for leadership. Topics include the growing power of data; the rising impact of urbanisation on health; increasing patient centricity; the need for more flexible organisations and the move of innovation activity eastwards.
Available as both this report and as an accompanying presentation (https://www.slideshare.net/futureagenda2/future-of-healthcare-15-october-2019-182433390) this is now being used to inform and provoke further debate around the world. As ever we would like to thank all those who have given their time and insight to contribute to this project.
EMPHNET Public Health Ethics (PHE): Introduction to public health ethics (phe)Dr Ghaiath Hussein
This is a series of presentations I gave in the Eastern Mediterranean Public Health Network (EMPHNET)'s Public Health Ethics (PHE) course that was held in Amman in June 2014.
It is a revised introduction to public health ethics.
The Important Role of Population Health Management in Enhancing Healthcare | ...Enterprise Wired
Benefits of Population Health Management: 1. Improved Health Outcomes 2. Cost-Efficiency 3. Enhanced Patient Experience 4. Health Equity and Accessibility
Introduction to Routine Health Information System SlidesSaide OER Africa
Introduction to Routine Health Information System was created for undergraduate and postgraduate health science students to introduce them to the concepts and methods of routine health information systems.
The learning objectives are to help users explain the roles of routine health information systems (RHIS) in health service management; examine strategies used to improve routine health information systems; acquaint with skills to carry out the process of improving RHIS performance; discuss three categories of determinants that influence RHIS.
Social Determinants of Health InequitiesRenzo Guinto
Lecture given during the pre-APRM workshop on Social Determinants of Health and Global Health Equity, September 11, 2012, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur
The course offers an opportunity to develop a holistic understanding of Global health, its functions, and scope. The course attendants will learn the principles of Primary Health Care, the course is expected to help the students to understand and internalize international health and public health transition facilitating the integration of health sector with other sectors.
Dear all
Please go through the slides if you want to know something about "Core competencies for public health informatics".
I think these slides will be useful for you.
Future of Healthcare – Leadership Challenges
Further to several additional expert workshops this year, we are delighted to share an updated global perspective on the future of healthcare. Produced in partnership with Duke Corporate Education (http://www.dukece.com), this adds new insights on the pivotal shifts taking place across the sector plus viewpoints on some of the core implications for leadership. Topics include the growing power of data; the rising impact of urbanisation on health; increasing patient centricity; the need for more flexible organisations and the move of innovation activity eastwards.
Available as both this report and as an accompanying presentation (https://www.slideshare.net/futureagenda2/future-of-healthcare-15-october-2019-182433390) this is now being used to inform and provoke further debate around the world. As ever we would like to thank all those who have given their time and insight to contribute to this project.
EMPHNET Public Health Ethics (PHE): Introduction to public health ethics (phe)Dr Ghaiath Hussein
This is a series of presentations I gave in the Eastern Mediterranean Public Health Network (EMPHNET)'s Public Health Ethics (PHE) course that was held in Amman in June 2014.
It is a revised introduction to public health ethics.
The Important Role of Population Health Management in Enhancing Healthcare | ...Enterprise Wired
Benefits of Population Health Management: 1. Improved Health Outcomes 2. Cost-Efficiency 3. Enhanced Patient Experience 4. Health Equity and Accessibility
Primary Health Care Strategy:
Key Directions for the Information Environment. Case study report and composite success model.
Steve Creed & Philip Gander
Day 1: Challenges and opportunities for better detection, diagnosis and clini...KTN
The focus of this session is to explore how the UK health system is currently responding to the increasing number of patients with multiple long-term conditions and the impacts of healthcare inequalities on patient outcomes. We will also explore opportunities for businesses to bring about much needed innovations in the prevention, early diagnosis and management of multi-morbidity.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
Use of Electronic Technologies to Promote Community and Person.docxdickonsondorris
Use of Electronic Technologies to Promote Community and Personal
Health for Individuals Unconnected to Health Care Systems
Ensuring health care ser-
vices for populations outside
the mainstream health care
system is challenging for all
providers. But developing
the health care infrastructure
to better serve such uncon-
nected individuals is critical
to their health care status, to
third-party payers, to overall
cost savings in public health,
and to reducing health dis-
parities.
Our increasingly sophisti-
cated electronic technolo-
gies offer promising ways to
more effectively engage this
difficult to reach group and
increase its access to health
care resources. This process
requires developing not only
newer technologies but also
collaboration between com-
munity leaders and health
care providers to bring un-
connected individuals into
formal health care systems.
We present three strate-
gies to reach vulnerable
groups, outline benefits and
challenges, and provide
examples of successful
programs. (Am J Public
Health. 2011;101:1163–1167.
d o i : 1 0. 21 0 5/ A J P H . 2 0 10 .
30 0 00 3 )
John F. Crilly, PhD, MPH, MSW, Robert H. Keefe, ACSW, PhD, and Fred Volpe, MPA
DURING THE PAST DECADE,
the United States has experien-
ced a rapid growth of electronic
health information technology in
hospital and health care provider
systems to enhance access and
quality for service recipients. State
health departments have devel-
oped health information ex-
changes across large health care
networks, insurance providers,
and independent physician prac-
tices, and the use of electronic
health records has greatly accel-
erated.1 These initiatives evince
progress toward achieving a fully
connected national health care
system by 2014.2
Nevertheless, cities and
counties struggle to understand
the health care needs of individ-
uals who do not or cannot easily
access formal health care net-
works but use expensive services
for emergency and routine care.
Health information technology is
currently designed to benefit pri-
marily populations already con-
nected to such systems. As systems
increase their use of health data to
influence treatment and policy,
developing strategies to include
individuals who are largely out-
side health care networks is criti-
cal.
The US health care system has
been criticized for low-quality care
that produces multiple medical
errors3,4 and high-cost services
that limit access to care,5 perpetu-
ating health disparities. Primary
care focused on preventing illness
and death is associated with more
equitable distribution of health
and better outcomes than is spe-
cialty care6---8; countries directing
resources to primary care and
enhancing population health have
lower costs and superior out-
comes.9 Although the United
States has the world’s most ex-
pensive health care system, other
countries regularly surpass the
United States on most health in-
dicators, including quality, access,
efficiency, ...
This paper presents analysis of a Kent ‘whole population’ dataset, linking wholepopulation demographics with activity and cost data for the population from acute, community, mental health and social care providers. The data helps commissioners to understand the impact of different selections methods for people with ‘very complex’ health and social care needs, particularly in relation to the development of a LTC year of care currency.
This document should be seen alongside the ‘Recovery, Rehabilitation and Reablement – step-by-step guide’ which describes how providers can carry out the audit in their own organisation. Other documents and learning materials This document is part of a suite of learning materials being produced by the LTC Year of Care Commissioning Programme to support the spread and adoption of capitated budgets for people with complex care needs.
Data Analytics for Population Health Management Strategiesijtsrd
Data analytics plays a pivotal role in population health management, offering strategies to enhance healthcare delivery and outcomes. This review article delves into the multifaceted world of data analytics in the context of population health management. It explores the utilization of health data for risk stratification, predictive modeling, and interventions tailored to the needs of distinct population groups. The article discusses the integration of electronic health records, wearables, and IoT devices to gather comprehensive patient data. Analytical methods, including machine learning and data mining, are examined for their capacity to extract insights from large datasets. The importance of data privacy, security, and ethical considerations in population health management is also addressed. In conclusion, this article underscores the significance of data analytics in optimizing population health management strategies and improving healthcare outcomes. Ravula Sruthi Yadav | Dipiksha Solanki "Data Analytics for Population Health Management: Strategies" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-7 | Issue-6 , December 2023, URL: https://www.ijtsrd.com/papers/ijtsrd60104.pdf Paper Url: https://www.ijtsrd.com/pharmacy/pharmacology-/60104/data-analytics-for-population-health-management-strategies/ravula-sruthi-yadav
This e-book focuses on Health Management Solutions the value it adds alongside other systems that are already in place throughout the care lifecycle...
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Artificial Intelligence to Optimize Cardiovascular Therapy
Break-out session slides Session 1: 1.1 Population health management in practice - Dr Karen Kirkham
1. Population health management in practice
Dr Karen Kirkham
National Clinical Advisor Primary Care NHSE
Jackie Chin, Deputy Head of PHM, NHSE
March 2019
2. 1www.england.nhs.uk
National context: what is population health management?
Population Health…
… is an approach aimed at improving the health of an entire population.
It is about improving the physical and mental health outcomes and wellbeing of people,
whilst reducing health inequalities within and across a defined population. It includes action to
reduce the occurrence of ill-health, including addressing wider determinants of health, and
requires working with communities and partner agencies.
Population Health Management…
…improves population health by data driven planning and delivery of proactive care to
achieve maximum impact.
It includes segmentation, stratification and impactabilty 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.
3. 2www.england.nhs.uk
Strategic commitments on PHM
Long Term Plan
ICSs will cover all of the country making shared decisions with
providers on how to use resources, design services and improve
population health. Each ICS will be required to implement integral
services that prevent avoidable hospitalisation and tackle the
wider determinants of mental and physical ill-health
Primary care networks will from 2020/21 assess their local
population by risk of unwarranted health outcomes and working
with local community services make support available to people
where it is most needed…..using a proactive population health
approaches to enable earlier detection and intervention to treat
undiagnosed disorders.
During 2019 we will deploy population health management
solutions to support ICSs to understand areas of greatest health
need and match NHS services to meet them. These solutions will
become increasingly more sophisticated in identifying groups of
people at risk of adverse health outcomes and predict which
individuals are most likely to benefit from different interventions.
We will be able to routinely identify missed elements of pathways of
care for individuals. In 2021/22 we will have systems that support
population health management in every ICS.
GP Contract 5 year Framework
Through their Integrated Care Systems,
NHS England will also ensure that
predictive analytical tools are
available to Primary Care Networks.
These will help them identify those
groups of people who are most at risk of
adverse health outcomes and
increasingly predict which individuals
are most likely to benefit from
different health and care
interventions. This is an important
enabler for the new Anticipatory Care
requirements
4. 3www.england.nhs.uk
There are three core capabilities for Population
Health Management
Infrastructure
• Integrated data architecture –
primary, secondary and social
care
• System wide Information
Governance arrangements
• Digitised health & care providers
and common health and care
record
Intelligence
• Advanced analytical tools and
multi-disciplinary analytical teams
• Actionable insights supporting
providers focus on population
health
Interventions
• Design and delivery of new care
models and anticipatory care
interventions which support an
integrated approach to physical,
mental and social care for target
patient groups.
• Building and utilising strong
partnerships with the voluntary and
community sector, with a specific focus
on reducing health inequalities
• Workforce and incentives
development based on population
health analysis.
Underpinning it all is the cultural shift required to put data at the heart of decision making across an ICS
5. 4www.england.nhs.uk
High risk
• Complex care management
programmes, intensive case
management and supported and
quicker transitions of care
Emerging risk
• Proactive risk based case finding and
management
• Prevention programmes, social
prescribing and community initiatives
• Improving access to extended MDTs/
primary care teams
Low risk
• Wellness and self care programmes
• More convenient access and digital
tools
Longtermconditioncomplexity
Wellness
Segmentation and stratification Impactability Tailored interventions
• Lifestyle factors
(diet / exercise)
• Social and
community
networks
• Genetics
• Money
• Education
• Housing
• Work /
unemployment
• Pollution
We want to help systems explore more advanced ways to
target and tailor clinical and non clinical interventions
Data supplemented with information
on social determinants and wider
influences
8. 7www.england.nhs.uk
NHSE’s PHM Development Programme is supporting four ICSs
to adopt data-led approaches to delivering proactive care
The programme has been designed to build capability and accelerate adoption of population health
management, with two overall aims:
1. Demonstrate proactive care delivery through Primary Care Networks using population health management
approaches
2. Advance population health management capability and infrastructure to enable sustainability across all tiers of
the system
Evaluation and impact System
roadmap
System Actuarial model
Tactical cohort (high risk, high utilisation)
Strategic cohort (rising risk, proactive care)
Upstream cohort (influencing wider determinants)
Cycle of learning
Identifying
the key lines
of enquiry
Data and
analytics
9. 8
This linked data enables health and care professionals to view the whole integrated system through the
lens of a single patient. This data can then start to be supplemented with information on social
determinants and patient reported data (eg through apps and wearables) to give a richer, more holistic
view of patient well-being.
Common
pseudonym
Registered People
List incl. disease
registries
(from GP systems)
General
Practice
(consultations
& prescribing)
Acute
CommunityMental Health
Adult Social
Care
Linked patient level data is the engine of PHM
Analytical
Approach
Description
Segmentation A method of dividing a population into smaller, more
coherent pieces, in order to better understand a specific
patient cohort. Simple segmentation involves analysis using
only a single dimension, but segments can be displayed in a
matrix format as well.
Intelligent
segmentation
The process of creating segments using statistical models.
Unlike simple segmentation, many dimensions, or variables,
can be used, and we can assess their validity and predictive
power with confidence in their statistical significance.
Risk
Stratification
A method of ascribing the likelihood of some adverse event
to a patient or group of patients, based on demographic or
clinical factors.
Intersegmental
Drift
The process whereby patients do not remain in a single
segment, but instead move between segments, based on
changes in demographic and clinical factors over time, such
as growing older, more complex, or developing specific
conditions.
Theographs Cross-sector patient timelines, showing a person's contacts
with health and social care over time
Population Health analytics glossary
10. 9www.england.nhs.uk
Systems are exploring how to use their local linked data to
understand their populations needs in different ways to
design and target interventions
Pounds per Person per Year
Total spend for cohort
Number of people in cohort
Step 1 – segmentation
By understanding different segments
of the population, systems can
understand where investments and
interventions may have the biggest
impact on the system as a whole.
This complexity model goes beyond
standard age-based or disease-based
segmentation models to truly look at
what makes a whole person ‘complex’
to treat, including multi-morbidity,
mental health issues, and social
demographics and determinant.
Each segment is Mutually Exclusive
and Collectively Exhaustive.
11. 10www.england.nhs.uk
For example, Leeds is exploring how to better meet the needs
of people with moderate frailty – using linked data to identify
who is most likely to benefit from interventions
Next stage is focusing in on
high risk and rising risk
patients within these
segments using risk
stratification to design and
implement proactive
interventions.
Step 2 – stratification
12. 11www.england.nhs.uk
Example of a COPD PHM cycle at Primary Care Network level
Clinicians and managers are aware
of Population Level Health Needs
Analysis and how that translates
to the population they serve
COPD prevalence identified as high
in GP practice and admissions to
hospital for COPD patients are also
high
Population is segmented
based on the need
identified
Patients on practice register
who are diagnosed with
COPD and at risk of COPD
(those who smoke) are
identified
Population risk profiling
of segmented population
Primary and secondary care
utilisation of those who are
identified is reviewed. High
users of services are
identified
Transformation using design and
implementation of effective
Interventions for the identified
need
Implementation of targeted smoking
cessation services. Referral to
pulmonary rehabilitation pathways
and MDT care planning for those
multiple conditions in addition to
COPD
Impactability modelling
Targeting care towards those with
the greatest ability to benefit
Of those who are high service users
which of those have care that is not
optimised? E.g. smoking cessation
advice not given, pulmonary
rehabilitation not offered, care plan
not in place/ in date, medication not
optimised
Evaluation of impact of
change against proposed
outcomes
Patient and practice level
impact on COPD
prevalence, related
emergency hospital
admissions and smoking
prevalence.
Knowledge of available effective
interventions to influence segmentation
13. 12www.england.nhs.uk
By linking data across the system, it is possible to track an
individual’s journey, spot gaps in care and streamline future care
Theographs…
14. 13
NHS England is developing support for systems
• PHM Maturity Matrix diagnostic sessions (infrastructure and intelligence)
• Data and Information Governance Network (being established) and PHM Data Governance Tool
• PHM Network and access to international learning webinar series
• ‘Flatpack’ guidance – an introduction to PHM
• Population Health Analytical Skills Audit – online tool
• Population Health Intelligence and Data Function Specification
• Library of good practice interventions and care models
• Access to accredited external transformation, digital and analytical support through HSSF
• PHM Dashboard co-design sessions
• To come……what does PHM mean for PCNs guidance and learning from ICS development
programmes
Email us at england.stgphm@nhs.net to get access to the PHM network
15. 14www.england.nhs.uk
Discussion
• What does population health management mean to you?
• What are some of the key barriers and solutions to making PHM business as
usual within Primary Care Networks?
• What support do you need to make this happen?