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Delivering data for a more personalised approach in the PHM Accelerator Programme

NHS England commissioned the PHM Accelerator Programme to support STPs and emerging ICSs to develop their PHM capabilities to manage their population better. We are providing integrated data sets to identify patients who would benefit from a more proactive, personalised approach to primary care.


Challenge

NHS England commissioned the PHM Accelerator Programme to support  STPs and emerging ICSs to develop their PHM capabilities to manage their population better. Berks West STP was one of the first phases to receive the 20-week Accelerator Programme support to help build their approach to understanding and dealing with the needs of their population. They needed to think and operate differently, to be a better predictor of future population demand, to understand patients may have more than one medical condition and to be able to segment and plan the service development needs to factor in Long Term Conditions (LTCs). In designing services and pathways the STP needed to also consider non-medical factors in addition to health and well-being factors, for example. whether someone is single or a couple, and accessibility and social factors that might affect them and to consider this from a population approach.

Approach

The Accelerator Programme provided the tools and skills in a multi-disciplined team (MDT) way with analysts working with clinical partnerships to deliver relevant packages of data enhanced by having analyst and actuarial support wrapped around it. The programme supported Berkshire West to understand complex data and statistics, identify what was important and the areas of their population to focus on. 1-2 areas of focus were identified for further investigation during the 20-week programme. SCW analysts were directly involved with the customer’s analyst huddles and helped to address the shortfalls in the approaches taken.

Data and analytics were provided by our teams, embedded in customers' offices and also through our Insights Population Analytics (IPA) solution. Using the tools available to us we developed an integrated data set that enabled actuarial analysis. We worked with clinicians to case find, using the IPA solution to identify and segment cohorts of patients to case manage. We were able to add value through this data analysis to enable greater segmentation from a clinical perspective within the broader population.

Impact

The Accelerator Programme enabled:

  • Proactive management of the programme provided an understanding of the PHM approach and enabled more PHM focused conversations
  • Supported clinicians to identify the important cohorts needing action.
  • The tools available ensured that the approach was evidence-based and backed by complex actuarial analysis.
  • The MDT approach included working with PCNs to ensure that practices and community teams were part of the discussion. The collaborative approach ensured that all relevant factors important in designing appropriate pathways were considered in identifying patient cohorts to concentrate on, including social, economic, demographic considerations.

The IPA tool is a convenient way to determine the number of contacts patients have with different parts of the health service. Although the tool offers more complex analysis, this simple aspect of the system can provide a 'quick-win', as a search takes a matter of minutes. From a practice perspective, it allows identification of patients who may have an increase in contacts and would benefit from a more pro-active, personalised approach. As data is needed to deliver a more personalised approach to primary care, the IPA tool is convenient as it provides this quickly and clearly. Dr Dan Alton, GP , Wargrave Practice and Population Health Management Lead, Berkshire West CCG

For more information contact Chetan Modha, Head of Population Health Management, This email address is being protected from spambots. You need JavaScript enabled to view it.

 

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