A ‘step by step’ guide to managing the pandemic of multimorbidity using Population Health Management

The increasing pressure on the NHS makes it clear we need to do things differently to sustain our health service for the future.

Whilst tackling the obvious pressures of today, a vast proportion of the NHS and partners are still working to prevent a ‘too big list’ of tomorrow’s problems.

An increasing body of international evidence shows that healthcare is delivered best as an integrated care system with person-centred care at its heart.

Data also tells us it is multimorbidity driving demand and cost – more than one in four adults in England live with two or more conditions and this is becoming the norm for older people and those from disadvantaged communities.

Despite diversity in their disease profile and circumstances, people with multiple conditions frequently share common problems such as reduced mobility, chronic pain, shrinking social networks, incapacity to engage with work, and lower mental wellbeing. To date, these problems have not been well addressed by services or research.

We tend to organise services around single conditions, doctors train in specialties, and research tends to take place on one disease at a time. This siloed way of thinking about morbidity doesn’t reflect the real world. People with multiple conditions want greater service integration, more person-centred, holistic care, and better support for mental wellbeing. To address this, innovative ways of intervening are needed, such as a Population Health Management (PHM) approach.

PHM is a radical shift in care delivery, a model for the planning and delivery of proactive, anticipatory care to achieve maximum impact within collective resources. It is an exercise in service design for the whole population, one cohort at a time, using data and analytics to guide us. It is a way of working to help frontline teams understand current health and care needs and predict what local people will need in the future. Read more about it on our integrated care web pages.

There are some great examples of this in practice, like in rural Dorset where hundreds of elderly people at high-risk of injuries were helped to stay well and understand their risk of falls at home plus reduce unnecessary medications and loneliness thanks to a community ‘carousel clinic’. The PHM team there linked data to identify their most at-risk patients and then a care co-ordinator invites those identified to the informal clinic at a local community centre where they talk to professionals such as pharmacists, advanced nurse practitioners and voluntary organisations like Healthier Homes. Read more about PHM on FutureNHS.

People often wonder how to start, but I say simply start with what you have. Here’s my step by step guide:

Step one

Prioritise: use data analysis or community stories to find priority areas such as unwarranted high cost or high demand, or unmet need or inequality of care. The wider and richer the linked system data, the more informed this decision making can be, but you need to get on with it using your ‘best available insights’. This can be cross referenced to compare against similar practices and areas, such as fingertips data and Joint Strategic Needs Assessment (JSNA).

Step two

Identify: Use data analysis (stratification and impactability modelling) to identify a cohort in your priority area for whom there is the best opportunity to improve the quality, efficiency or equity of care. This may include a particular condition(s), or more likely a group of conditions or just “comorbidity” or “complex needs” within a geographic area, a particular demographic (age, ethnicity) or those at risk of a hospital or care home admission.

Step three

Understand: use a wide lens to include the broadest range of available existing insights and include the patient’s and carer voice to understand your cohort. Seeing it from the patient or citizen side will address wider determinants of health and consider health inequalities. Use this broad view to get a clear picture of the existing resources and services.

Step four

Design: In designing a new model of care to deliver better outcomes, ask questions such as:

  • What are the needs of the cohort?
  • What outcomes do you need to see in order to meet these needs?
  • What activities do you need to do to achieve the outcomes?
  • What resources and skills do you need to invest to do those activities?

Step five

Implement: the ‘how’, ‘who’ and ‘what’ involved in making it happen. You need to ensure necessary buy-in from system leadership and stakeholder organisations for the support, co-operation and IG processes to deliver the plan. From the outset plan how, you will measure the outputs and outcomes including both care provider and patient/user feedback. Keep the process agile, adapt as you learn.

Step six

Evaluate and expand:

  • Did you reach the target group?
  • Did you achieve the intended outcomes / outputs?
  • What worked well and what can you improve?
  • Do you need to make any changes based on your evaluation?
  • How can you scale up/ share your plan?

Trust in the process. Involve all relevant stakeholders and the patient or citizen at every stage from information gathering, planning and designing to delivery and evaluation. Make sure to combine best laid plans with pragmatic delivery.

If you’re looking for more inspiration, visit the PHM Academy on FutureNHS for all the latest best practice and case studies from around the country.

Population Health Management is key to enable the delivery of integrated care systems and needs to become embedded in the day-to-day targeting care appropriately effectively and efficiently.

Dr Helen Davies

Dr Helen Davies is a GP clinical lead for community and population health management in Calderdale which is part of West Yorkshire Integrated Care Board. Follow her on Twitter @HelenDa21136593 and connect with Helen on LinkedIn.