This presentation is for a senior clinical engagement event on Population Health Management Approaches and how we intend to apply them

1. Hertfordshire and West Essex
Sustainability and Transformation Partnership
POPULATION HEALTH
MANAGEMENT
JIM MCMANUS, DRAFT 2
SEPTEMBER 2018

2. Hertfordshire and West Essex
Sustainability and Transformation Partnership
Acknowledgements
• Sue Matthews and Linda Mercy (HCC Public
Health)
• Dr Steve Laitner
• Public Health England
• Association of Directors of Public Health
• The King’s Fund

3. The Triple Aim
Better care
for
Individuals
Better health
for
Populations
Lower Cost

4. Engaged Communities
• Proactive care processes
• Identified patients
• Focused on wellness
• Community resource navigator
Engaged Patients
• Identified and incorporated
patient goals
• Focused on continuity and
coordination
• Facilitated communication
channels
• Improved access to care
Identified Opportunities to Reduce Waste
• Duplication avoided
• Improved coordination/transitions
• Used automation to reduce resource needs
• Improved screening and prevention
• Aligned incentives to drive value
Achieving Success
Making the “Triple Aim” Possible
Better
Health
for the
Population

6. • At strategic and operational level this needs to
identify actions for different agencies, from
the NHS to local authorities, third sector and
others. How well we understand our
competencies, the fact we ALL have a role –
and there are STRONG clinical components to
this for EVERY clinician, and who is best placed
to do what will determine whether this
approach ever gets off the ground
6

7. System Approach
7

8. Population Health
‘The health outcomes of a group of individuals, including the
distribution of such outcomes within the group’ (Kindig and Stoddart)
Influences include healthcare, but more importantly lifestyle, local
environment, wider determinants of health etc To achieve a
population health model we need agencies at all levels to work
together – population health is everyone’s business
The Population Health ‘opportunity’ is to establish new models that
address health, care and wider determinants
Eg STP Social Prescribing project, Safe and Well, Warmer Homes

9. Population Healthcare
• Maximising Population Health outcomes through healthcare
• Population Healthcare has been defined by Public Health England as
healthcare in which:
• “The aim of population healthcare is to maximise value and equity
by focusing not on institutions, specialties or technologies, but on
populations defined by a common symptom, condition or
characteristic, such as breathlessness, arthritis, or multiple
morbidity.”
• Eg STP 100 day challenge work for palpitations, RightCare
programme etc

10. Population Health Management
• Proactive application of strategies and interventions to
defined groups of individuals, to support prevention and
chronic disease management - whilst managing costs
• This includes –
assessing population across the continuum of care
stratification and modelling of defined ‘at risk’
populations
development of management plans depending on each
groups needs
surveillance
performance management etc

11. Our focus for this session is going to
be on Population Health
Management...
11

12. A BIT MORE ABOUT WHAT IT IS...
12

13. Definition
‘Population Health Management improves population health by data driven
planning and delivery of care to achieve maximum impact. It includes
segmentation, stratification and impactability 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.’
Data informed planning to improve health outcomes by ensuring the Right
Care to the Right People at the Right Time and Place.

14. • Population health management is
a proactive approach to managing the health
and well-being of a population. It aims to
incorporate the total care needs, costs and
outcomes of the population.
14

15. • STRATIFYING – By need/risk/severity
• SEGMENTING – By lifecourse stage
• IMPACTABILITY – What will be the outcome of
doing this and WHERE -primary care,
secondary care,social care, community
15

16. Generally well
Long term
conditions /
Long term
needs
Complexity of
LTC(s)
and/or disability
Low
risk
High risk Low risk High risk Low risk High risk
SEGMENT
Children and
Young People
• Neonates
• Infants
• Toddlers
• Children
• Adolescents
STRATUM STRATUM STRATUM
SEGMENT
Working Age
Adults
• Young
• Middle aged
• Older working
age
SEGMENT
Older People
• 65-80
• 80-90
• 90+
01/09/2018 Dr Steve Laitner
With thanks to Steve
Laitner for this slide

17. Stratification
• People who are generally fit and well need access to high quality
and effective primary prevention interventions in order to prevent
disease and stay well.
For example, childcare, education, family support, physical activity, employment, housing, social
interactions, diet, avoiding smoking and drugs, safe alcohol consumption
• People with long term conditions need to be identified early to help
them stay well and prevent future complications.
For example through community based help, personalised care planning, self-management support,
medicine management and secondary prevention services.
• People with complex comorbidities need personalised care to
maintain their quality of life.

18. Population Health Management
Case
Management
Specialist Disease Management
Supported Self Care
Population-wide prevention

19. 19
Robert
Wood
Johnson
Foundation,
2014
Requires a collaborative strategy
between leaders in healthcare,
politics, charity, education, and
business
True Population
Health
Management

20. BUT THERE IS MUCH THAT THE NHS
CAN AND SHOULD DO, AS WELL AS
PARTNERS, WITHIN THE PHM
FRAMEWORK
20

21. Children and Young
People
Working Age Adults
Older People
Population health cube
© 2017 National Association of Primary Care01/09/2018 Dr Steve Laitner

22. Kent Integrated Dataset (Source:
Carnall Farrar)
Generally well/good wellbeing
Long term condition(s)/
social needs
Complexity of LTC(s)/ social
need and/or with disability
Children and
young people*
Working age
adults
Older people
£56.3
M
-
-Population, thousands Spend, £ millionsSpend per head, £
£7,50
7
Elective
Outpatient
Acute Other
Community
Adult social care
Non-elective
A&E
Mental Health
Primary
£309.3
M
£5,94
8
£9.2M
£4,00
0
£26.8
M
£940
£907.1
M
£1,72
1
129.2
£315.9
M
£2,44
5
257.2
£109.4
M
£425
501.8
£174.9
M
£348
21.6
£39.4
M
£1,82
4
28.5
527
52
7.5
2.3

23. 23
Population segmentation reveals vast differences in resource
consumption by difference groups of population
Source: Kent Integrated Dataset, Carnall Farrar analysis *NOTE: Excludes Children’s Social Care 8
Generally well/good wellbeing
Long term condition(s)/social
needs
Complexity of LTC(s)/ social
need and/or with disability
Children and
young people*
Working age
adults
Older people
- -Population,
Thousands
Spend, £
Millions
0.3 1.9
Spend per head, £
1.7 10.3
0.1 0.31.0 0.9
17.6 30.2
4.3 10.5
8.6 3.6
16.7 5.8
0.7 1.3
7,507
5,948
4,000940
1,721
2,445
425
348
1,824
50k population in Kent and Medway

24. INCREMENTAL APRPOACH
Focus on gains which can be made easily and systematically,
identify areas where most “health gain” can be made
This is NOT about saying “it’s all about wider determinants” or
“well we have to do primary prevention” IT IS NOT
There are cohorts of people already morbid, in the system, where
evidence shows this approach can produce benefits in short,
medium AND long term
24

25. • Worth noting that PHM is not new.
– Eg Stratifying group populations by risk is something we already
do
– Disease management programmes exist for those identified
• What is different now?
– We want to work with partners and develop more co-ordinated
approaches to improving population health, reduce costs etc –
need to share data to do this
– New STP/ICS geographies – including 30-50k ‘neighbourhoods’
– Technological advances…

26. ICS Performance and PHM Dashboard
(press release 26th March 2018 )
• Imperial College Health Partners are excited to announce that we have won a bid, in partnership
with Cerner, OptiMedis-COBIC UK and NEL Commissioning Support Unit to provide a new
performance and population health management dashboard for NHS England and Integrated Care
Systems (ICS) across the country.
• This new performance and population health management dashboard will build on the current
reporting system, which is largely focused on separate performance metrics. It will also provide a
way to monitor activity, population health, identify and effectively target resources to improve
patient outcomes by joining together disparate elements of the health and care system. It will
enable more preventive solutions to healthcare through its ability to track, predict, intervene and
manage conditions cost-effectively.
• The programme is working collaboratively across national organisations and four first-wave ICS sites
(Nottinghamshire, Yorkshire and South Cumbria, West Berkshire and Bedford, Luton, Milton
Keynes) to develop the first iteration of the dashboard, with a view to roll out to other first-wave
sites as the programme progresses.

27. HOW DO WE GET THERE?
1. COMPONENTS
2. COMPETENCIES
27

28. THE CORE COMPONENTS OF
POPULATION HEALTH MANAGEMENT
28
Stratification

29. Four Core Components
Mindset. Evidence. Culture. Interventions
• Mindset
– Workforce Attitude, Culture and Skills
• Evidence
– Analytics, Informatics and Data – getting the data to help drive
decisions and approaches
– Evidence of what is effective
• Culture
– A culture which puts this approach into action every time
• Interventions
– Pathways – being able to pathway people and shifting
investments to make it happen
– Interventions – knowing the intervention

30. THESE FOUR COMPONENTS NEED TO BE
TURNED INTO WORK PROGRAMMES
30

31. THE CORE COMPETENCIES OF
POPULATION HEALTH MANAGEMENT
31
PHE Grid of competencies being developed. Here is the draft....

32. Levels 1(
lowest) to 5 (
highest) for
each
dimension. 1 2 3 4 5
Population
approach
No identified
populations
Some identified
populations with
NEEDS
ASSESSMENT and
nascent EVIDENCE
BASED models of
care
Mature models of
patient-centric care
for LTCs, dementia
and key
subpopulations
Mature models of
care for most
elements of
population
INCLUDING
FORECASTS OF
NEED
Evidence-based
care
pathways supporti
ng all populations/
key conditions
Inequality
reduction
No consideration
of inequalities
Inequalities
considered
sometime in
decision making
Inequalities well
understood;
regularly
considered in
decisions
Inequalities
systematically
considered in all
decisions and this
assessment
changes actions
taken
Inequality
reduction
monitored and
evidenced in all
organisational
decisions
Prevention No consideration
of prevention;
interventions are
reactive
Prevention
considered
sometimes in
decision making
Prevention well
understood;
regularly
considered in
pathways of care
Prevention
systematically
considered in all
decisions and
actively invested in
Full primary
prevention
programme across
all major risk factor
areas and health
determinants;
Working towards
fully engaged
population.

33. Levels 1(
lowest) to 5 (
highest) for
each
dimension. 1 2 3 4 5
Use of
evidence in
decision
making
No regular
evidence use
Some evidence use
in key decisions;
majority of
decisions made on
case studies and
anecdotes
Regular use of
evidence in all key
decisions
Systematic use of
evidence.
Regular evaluation
which affects
decisions
Evidence use and
evidence
generation with
mechanisms that
enable behaviour
change for those in
the system
Metrics and
Measurement
for
Accountability
No metrics or
measurement; no
accountability
between providers
Outcomes
framework for
some elements of
care, limited
shared
accountability
Tracked outcomes
for all patients,
within most parts
of care continuum;
Patient and
population
outcomes
Tracked outcomes
framework for all
patients and
populations with
clear
accountabilities.
Assessments of
effectiveness,
efficiency, cost-
effectiveness ,
acceptability and
access.
Tracked outcomes
framework for all
patients and
populations with
clear
accountabilities
including social
care.
Assessments of
effectiveness,
efficiency, cost-
effectiveness ,
acceptability and
access.

34. Some groundrules
• Don’t start with primary prevention, start with
the populations who are already in the
system, and where gains could be made most
quickly and easily
• What can be made “routine”? (eg smoking
cessation as core part of respiratory care)
34

35. Four Critical Success Factors, Many Hurdles Along the Way
Achieve Data Transparency to
Manage Utilization
• Hard to arm physicians with information due to
limited transparency provided by payers
• Difficult to link and reconcile disparate data sets
using data warehouse solutions
• Internal clinical and financial systems constrains
visibility to utilization inside organization
Prioritize Patients at Highest
Risk of Poor Cost and Quality Outcomes
• Predictive analytics required to forecast outcomes
with accuracy not a core competency of EMR,
financial system vendors, or providers
• Lack of robust benchmarks prevents identification
of actionable opportunities based upon gap to
benchmark
• Limited visibility into psycho social factors
Focus Interventions on Highest
Prioritized Opportunities
• Lack of integration between analytical and
workflow tools prevents effective execution
• Difficult to quickly identify and engage the
appropriate resources for each intervention
• Limited ability to bring together timely clinical
and financial risk data for clinicians at the point
of care
Measure Impact of Interventions and
Continuously Improve
• Difficulty linking cost and utilization data
hinders ability to track and trend PMPM costs
• Data complexity prevents routine analyses with
frequency required for course correction and
continuous improvement
• Difficulty connecting productivity of care
managers to outcomes and return on
investment
Clinic
ian
Com
missi
oner
1 2 3 4

36. 36
Prioritize Population-level
Improvement Opportunities
Proactively Manage
Individual Patient Health
Evaluate Effectiveness of
Interventions
• Who are my highest-risk patients?
• Which diagnoses are contributing
most to avoidable utilization?
• Are these patients receiving
recommended care?
• What interventions would decrease
avoidable utilization?
• Did these interventions reduce
avoidable utilization?
• Were our medical homes successful
in decreasing PMPM costs?
The Crimson Population Health Solution
Critical Feedback Loop
New Insights Achieved by Marrying Clinical Data with Total Cost and Utilization
Population Risk Management
+ Care Management
Workflow + Care Gap
Analysis
Functionalities Achieved
through Platform Integration
Linking clinical values
with claims data
Enables multivariate
analysis of utilization,
claims and clinical values
for superior population
health management
Population analytics
at the point of care
Integrates population-
level risk analytics with
point-of-care clinical
workflow tools,
enabling prioritization
of high-risk patients for
targeted interventions

37. • Availability of good quality & consistent info
and advice is key – For example, ENHCCG are
developing dietary advice for people with pre-
diabetes
• Personalisation – about having choice and
control. This should be a theme running
through all programmes?

38. POPULATION HEALTH MANAGEMENT
CRITICAL SUCCESS FACTORS

39. The goal of population health is to transform care delivery practices and administrative
support to deliver improved outcomes and lower costs across the continuum of care for a
specified population. Success will depend on changes in care practices, business processes
and cross-organizational communications, all supported by information technology.
Clinician Engagement
Cross-Continuum Care
Delivery and Medical / Care
Management
Quality Outcomes
Management / Reporting
Operational Performance
Management and Business
Informatics
Right Investment,
Right Place
Integration and Infrastructure