Healthy Wirral

1. Healthy Wirral
Primary and Acute Care System
Vanguard Site
Jo Goodfellow, Programme Director
9th December 2015

2. Our new model of care

3. What’s our USP?
The Healthy Wirral population health
management approach will be
underpinned by a robust population
health management platform supplied
by our informatics partner who have
extensive experience of working with
accountable care organisations that
are moving from a fee for service
model to a value based model.

4. We will create a new care record

9. Focusing our approach
Information Governance
Engagement of stakeholders
High level benefits realisation

10. Information Governance
• Information Governance Task and Finish
Group
• Working in partnership with Information
Commissioners Office/HSCIC
• Development of Privacy Impact
Assessment and Information Sharing
Agreement
• Memorandum of Understanding

11. Information Governance-What did we learn?
• Constantly explore the art of the possible
• We are learning too!
• Cross every bridge when you come to it
• Seek subject matter expert advice
• Take your senior leaders with you

12. Stakeholder engagement
• Understanding local history and current
news headlines
• Clear understanding of the change being
implemented
• Stakeholder engagement strategy
• Benefits analysis

13. High level benefits of the Population Health
Management system
Benefit Type Description
Prevention  Ability to stratify records distinguishing high risk, rising risk, and low risk.
 Interventions to prevent patient condition deteriorating
Intervention  Tracking compliance to care pathway management
Joined-up care  Efficient consultations through the ability to view health and social records in one place (longitudinal
record), leading to less time chasing information and improved clinical outcomes.
 Improved care coordination
Decision support  Shared registries of patient condition groups with ability to filter and aggregate by population or
organisation.
 Pro-active monitoring (e.g. vital signs) to prevent deteriorating health.
Patient quality and
experience
 Improved communication between organisations.
 Reduction in duplicated tests.
 Reduced length of stay.
 Reduction in avoidable admissions and re-admissions
 Reduction in adverse drug interactions.
Patient self care  Pro-active targeting of patient condition groups for enabling patient self care (Social Prescribing)
Population Management  Opportunity to review commissioning model with improved intelligence and tracking of patient
outcomes.
 Opportunity for Integrated Care Co-ordination Teams that provide a responsive and person-centred
approach to delivering both planned and unplanned care at home. Improve independence and
wellbeing in order to avoid hospitalisation.

14. Where are we now?
• Public engagement commences (January)
• Memorandum of Understanding between
Partners (December)
• Building and implementation of Diabetes and
Respiratory registries (on-going)
• Commence Wellness and Depression
registries (December)
• Sharing our learning and ensuring
replicability (on-going)

15. What matters to you?