The steps to a mature Population Health Management system

Improving overall population health outcomes

Population Health Management (PHM) is an iterative process, with the extent of improvement in overall population health outcomes dependent on how quickly the critical success factors. Most examples of PHM that are delivering measurable outcomes have been operating for many years. In England, while there have been localised examples of attempts to adopt a PHM approach, these have generally been aimed at a specific population, with limited of adoption at scale. This has now started to change, with the creation of the vanguards and the ‘Integrated Care Systems (ICSs)’, as well as the Devolution agenda.

The NHS Long Term Plan (LTP) acknowledges that delivering the plan will depend on local health systems having the capability and capacity to implement changes effectively. It also highlights the need for a roll-out of PHM tools. This will enable ICSs to identify groups at risk of adverse health outcomes and inequalities, and to plan services accordingly. ICSs will also require changes to funding flows and performance frameworks, and a new ICS accountability and performance framework will be introduced to consolidate local performance measures alongside a new integration index for measuring patient and public views about local service integration.

Implementing a PHM approach Deloitte have developed two maturity frameworks to assist in understanding the steps needed to implement an effective PHM approach. By evaluating the existing situation against the component parts of a mature PHM system, organisations can assess where they are currently strong, what further work skills are needed to help drive further progress, and identify those areas that require improvement.

Applying the population health maturity assessment framework The PHM framework (see Figure 9) addresses overall system maturity and enabling factors such as system leadership and governance, culture and engagement, data and analytics, technology, and financial and organisational models. Applying the PHM maturity framework helps provide health and care systems with an understanding of progress. It can be used by system leaders to agree a pathway towards achieving a sustainable model, whilst also working towards increased levels of risk sharing by aligning financial risk with incentives, driving better performance and improving quality.

The population health IT and data analytics framework Technology underpins all nine critical success factors. It is therefore important that the correct IT and digital infrastructure is in place to enable PHM to operate effectively across different healthcare systems and organisations and become part of an integral approach. The use of technology improves the efficiency and effectiveness of performance monitoring and financial planning, the application of financial incentives, the re-design and management of clinical workflows, and the implementation of services at scale.

Tools for delivering population health are evolving quickly but are still somewhat silobased. Funding for the tools across geographies and boundaries is also complex as is agreeing ownership of the analysis. The key requirements for implementing the appropriate technologies include:

  • Prioritising the features needed in a roll-out process
  • Designing the solution, through a clear understanding of needs to change, why and how
  • Implementing the solution with clinician support and recognition that this is a change management project
  • Monitoring progress against metrics, requiring extensive business and clinical analysis and feedback throughout
  • ‘Rinse and repeat’ to reflect the fact that PHM is an agile process, including learning about the clinical, social, emotional and logistical needs of each population, and tailoring solutions to fit the needs of the community.

Options for the optimal solution

There are four options to consider:

  • Integrate PHM as part of the EHR solution. Given that it is often easier to work with an existing system, even if it isn’t as efficient as it could be, many providers have opted either to use their existing EHR modules or to customise their EHR to meet the needs of the PHM solution. This often requires not only a large capital expenditure but also investment in continuing operating expenses to keep the system running
  • Use a parallel system and solution. There is a plethora of off the-shelf PHM solutions in the market, from analytics to care management and reporting solutions. Many providers opt to integrate the data from their EMR solutions into an off-the-shelf PHM solution, placing responsibility for software maintenance on the vendor
  • Build it yourself. Some providers prefer to build their own system of analytics, care management, and overall PHM. Although this option is becoming less common, it has merits, as it provides full control over the iterative R&D process and solutions are tailored to the needs of the population
  • Create a hybrid. This is probably the most common approach where a combination of home-grown and vendor-led solutions is developed

Further considerations

As all health and care organisations become an integral part of an ICS and work collaboratively to adopt a PHM approach there are several other considerations to keep front of mind. Start with a clear vision of what is needed. Not all aspects of PHM need be done by providers. Decide what can be outsourced. The vendor landscape is constantly changing, so re-evaluate the approach continually and change it if and when needed.

Define what success looks like. It is easy to get lost among too many disparate goals. Create a manageable number of key performance metrics that define success, such as cost of care per episode, per bundle, or per patient. Create a clinical dashboard targeted towards the specialties that are relevant to providers and patients. By bearing these points in mind and giving due to consideration to each discrete area within the two frameworks described above, the rate of progress to achieving a fully integrated and mature PHM approach can be accelerated.  

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