The term 'population health' implies that there are a wide range of determinants of health and well-being that sit beyond health and social care services that determine the health of the population i.e. social, environmental, cultural and physical factors that impact upon the health of human populations. By reducing the impact of these factors, you can reduce the health inequities and inequalities among different population groups. It is much more of a sociological approach rather than starting with the variations between groups and working backwards to determine the causes or reasons for the disparities.
Population health's value lies in its focus on the distribution of health (i.e. health will vary between and within populations) and the facilitation of knowledge across the many factors that influence health outcomes. This can enable different policy and decision makers to find a common language or interest in which to work together.
Population Health Improvement
In England, population health is a key component of the NHS Long Term Plan and the establishment of the Integrated Care Systems (ICSs). ICSs are expected to redesign care, improve population health and address the wider determinants of health.
Population health improvement therefore is about:
- Reducing the occurrence of ill health,
- improving health outcomes of the population
- Improving physical and mental well-being of people in a defined population
- Delivering appropriate health and social care services
- Working with communities and partners on the wider determinants of health.
What is meant by Population Health Management?
Population Health Management (PHM) is the methodology or the way of working to help bring about population health improvement. It uses data to drive the planning and delivery of proactive care and improve population health and reduce health inequalities within and across a defined population. It takes into consideration the factors that impact upon health such as lifestyle and behavioural factors, environmental, societal factors, socio-economic and healthcare factors. The idea is to improve health and remove inequalities by taking actions to reduce the occurrence of ill-health. This is done using data-driven insights and evidence of best practice to inform, plan and deliver
targeted, proactive anticipatory care interventions within a defined population.
PHM starts with the analysis of data (information) to identify the cohorts or population segments where interventions can add value. It is key to understand the population and their health and care needs. Population segmentation/stratification and impactibility modelling are then used to identify those people who could benefit the most from the interventions. This is often based on risk and it helps to identify the local 'at risk' or vulnerable cohorts. Predictive system modelling (i.e. modelling of expected outcomes under different scenarios using person level data) is often included to consider the impact on health, finances and sustainability. Following this, interventions can be designed and targeted to prevent or reduce ill-health and improve care (e.g. in people with ongoing health conditions like diabetes). PHM can then be used to measure and monitor the impact of the interventions.
There are five main uses of Population Health Management:
- To enhance experience of care
- To help improve health and well-being of population
- To address health and care inequalities
- To reduce the per capita cost of healthcare and improve productivity
- To increase well-being and engagement of the workforce
Uses of Population Health Management
Hospitals are using PHM to better manage their patient flow. This method places an emphasis on patient outcomes and quality of service, shifting hospitals from traditional reimbursement based on volume of procedures to improving patient experience of care, reducing costs and focusing on keeping people well in the community. This has led to the investment in telemedicine, community-based (urgent care) clinics in areas with high proportion of residents using the emergency department as primary care, and patient care coordinator roles to coordinate healthcare services across the system.
PHM has become pivotal to the way that systems work together to improve the health of their populations. Within the ICSs in England, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases. Providers are encouraged to keep their patients healthy and out of the hospital. The intention is that inpatient admission and emergency department rates will drop. This builds upon the experience during the COVID-19 pandemic. Primary and secondary care providers used PHM to risk stratify and proactively support key population groups with personalised care models.
On a GP practice level, I have heard conversations around GP practices using PHM in the planning and running of their services. This effectively means helping them to think beyond the day-to-day management onto understanding who their population is, the variation in health conditions across the population and the patient outcomes they want to achieve.