Best Population Health Management Solutions
Are you unsure what the difference between population health and population health management is? Or do you know the difference but you are not sure how to implement it to have effective population health management? Or, are you just curious to see what software solutions are available?
By the end of this article, all these questions should be answered for you.
At The Access Group, we are aware of how health and care needs are changing. People are living longer with poorer health and some of our behaviours are increasing the risks of preventable diseases like type 2 diabetes.
We know that health is more than just medical; it can be affected by social, economic, environmental, and political factors out of our control too.
We work hard therefore to provide an eco-system of joined-up digital solutions to help you deliver and support better person-centred care to ensure better population health management outcomes.
In this article, we will compare the differences between population health, and population health management, whilst explaining why it is important locally, regionally, and nationally too. This article will then explain how different digital tools can help deliver effective population health management depending on your local community’s needs and goals.
What is population health?
Population health is the process of gathering health outcomes across a population in a specific area including the distribution of these outcomes across that area. The process involves using a co-production approach with a number of parties including the NHS, local authorities, VCSFE, and political leaders to include and consider the impacts which the wider social determinants of health can cause.
Population health outcomes can be measured in bigger or smaller groups from different geographical areas. They can be measured locally, regionally, and nationally. Population health outcomes can also be measured by various socioeconomic factors including age, gender, and ethnicity.
It is dynamic and constantly evolving, meaning that continuous learning, innovation and evaluation methods are needed to achieve positive and sustainable outcomes.
It is argued that a population health approach is one of the top four priorities for Integrated Care Systems (ICSs) in England.
Clinicians are thought to play an important role and act as leaders to suggest wider population health interventions that would be most appropriate, practical, and relevant to a population group.
What is population health management?
Population health management is the approach where shared data is used to understand the care and support needs of the whole population so resources can be targeted and shared to those who need it.
The population health management approach allows local communities to act and tailor their services to make better use of public resources when budgets are stretched.
Different organisations will work together using historical and current data about people’s health to design new proactive models of care to improve the health and wellbeing of individuals now, and in the future to help reduce health inequalities across the country.
Why is population health management important?
Population health management is important as it allows communities to ensure more beneficial provisions are in place to best support individuals needs to deliver better health outcomes.
Currently 1 in 5 GP appointments are for non-clinical issues. GPs are under huge amounts of pressure therefore to reach demand and reduce waiting times. Population Health Management helps primary care and integrated care systems take a holistic approach to ensure all individuals get the support they need when they need it. This, in turn, helps individuals who need more social support receive it in a timely manner to improve their mental health and wellbeing as well as reduce pressure on GPs.
With every in-person GP appointment costing £42 on average, through using a population health management approach GP attendance can massively reduce resulting in cost savings across several different primary care settings that can be spent in other areas to improve outcomes further.
Studies have found that loneliness and isolation can impact health to the same levels that risk factors like smoking can.
Having effective population health management is crucial therefore to help communities in several different ways including:
- Encourage more person-centred care
- Encourage more patient involvement
- Disease prevention
- Reduce gaps in provision
- Reduce GP attendance and hospital admissions and readmissions
- Reduce costs
Examples of why population health management is important
To ensure Integrated Care Systems (ICS) help deliver beneficial population health management, the NHS have released examples of what good population health looks like and why it is important.
One example identified how by jointly analysing data and finding ‘at risk’ individuals, local primary networks in Blackpool were able to design new anticipatory care models. This helped social prescribing link workers and well-being practitioners connect with the right groups in the community to address the wider social determinants of health they might be suffering with.
Population health management is important therefore as it identifies where individuals in a community need help and the approach offers organisations to adapt their services to best meet their needs to improve the health and wellbeing of their service-users, reduce costs, and deliver better joined-up care.
How to start the population health management process?
With the goal of population health management being to establish a cohesive approach that ensures all individuals have access to a comprehensive program to lead longer, healthier, and happier lives, having the right foundations in place is crucial.
Here are the 4 key steps to follow to ensure that population health management delivers better outcomes:
1. Define your target population or populations
This first step is vital. Without knowing what population you will be targeting you will never be able to measure its effectiveness, or understand what needs a particular population may have.
A population who is assessed as high risk will have different needs to a population with low risk, and will have different needs to individuals assessed as medium risk
Also, one population might not have the same needs. If your targeted population is on a larger scale, then they may have lots of different needs and other socioeconomic factors impacting their health compared to a local level. Similarly, a targeted population that is on average older, or more economically disadvantaged will typically face different factors to younger, more affluent population.
By defining your target population and their needs, you can solidify your population health management strategy. Here you can investigate what services have worked well for similar populations and check that your local community has the capacity to deliver the care and support needed.
2. Set and measure your outcomes
Once you have defined your target population and their needs the next step in the process is to decide on the metrics used to measure your outcomes.
This may differ depending on the outcome you are trying to improve.
For example, if your targeted population is located in a more deprived area and are suffering with stress and anxiety from unstable living environments, measuring wellbeing scores after attending or receiving support could be a beneficial metric to use.
However, if your targeted population is an older generation and the aim is to provide preventative care for more vulnerable residents in an area, then measuring GP attendance and hospital admissions might be a good metric to follow.
Without understanding the outcomes, you want to measure you will be unable to identify whether your approach to improving outcomes and individuals’ health and wellbeing is successful.
3. Decide how to monitor your outcomes
For population health management to be effective there are multiple different solutions, software, and digital tools that can be used. However, not all of them will be practical depending on the population’s need.
It is important to identify how you will record and monitor your outcomes. This will allow you to work collaboratively with other organsiations whether it’s GP practices, local councils, or support services and interventions. Through doing this outcomes can easily be monitored to spot trends and identify if the needs of a population are changing and therefore whether the approach needs adapting.
4. Review, share, and exchange results
A massive part of the population health management approach is that it only works successfully when different organsiations work together to share data and findings.
It is important that this happens consistently, this is because as population health keeps changing, and different socioeconomic factors and social determinants of health impact individuals differently over time, so do their needs.
Without sharing data and findings with other organisations in your local area your approach will never be able to evolve, progress, or grow to continue delivering better outcomes.
How can technology help deliver effective population health management?
With the main part of population health management being collaborative data sharing across multiple organsiations, technology is crucial to ensure data is shared quickly, efficiently and securely.
Without technology the process would not work. It would take significant amounts of time and by depending on manual and paper processes there would be a risk of data being lost leading to hefty fines and reputational damage.
Through digitally transforming your processes, both different outcomes and populations can be monitored at different risk levels to easily identify where there are gaps in your approach. It will be able to show the journeys that individuals and their population have gone on to identify if the issues you were addressing for a targeted population were successful.
What are the best population health management software solutions?
To decide which software solutions will be best for your community’s population health management approach, at The Access Group we recommend you answer these key questions to identify what help you need digitally.
- Do you have a clear picture of the socioeconomic issues facing individuals in your targeted population? E.g. What is the average literacy rate? Does everyone in the population have internet access?
- Do you understand the health and support resources and services currently available for the targeted population?
- Have you assessed where you will get the data from and what organisations you will work with?
- Have you decided how the outcomes will be assessed and monitored, or do you need more guidance?
- How will you ensure all end-users will be trained to use the solutions to ensure accuracy in recording your outcomes?
By answering these key questions your local authority, Integrated Care System, or Primary Care Manager will have a clearer understanding of the type of software and solutions that will be needed to achieve your aims.
As we have discussed, throughout, every target population will have differing needs and objectives, and because of this some software will be more effective than others.
Here are some examples of solutions and software that best suit 5 key objectives of population health management:
1. Encouraging more engagement
To ensure increased involvement from individuals of your targeted population and more deliver more person-centred care many organsiations benefit from using automated communication software.
A study by HealthcareITNews stated that 46% of their respondents identified they would use some form of automated communications to deliver better population health management.
Automated communication technology can be used in a variety of ways across the different organisations your local authority may be working with:
- GP Practices can send alerts to remind individuals suffering with long-term condition they are due their next review or need to book in a blood test
- VCFSE organisations and charities can send out what’s on emails to individuals in the population that sign up to the mailing list to inform individuals of the groups and support services available which could help them
- Local councils can send out automated emails to individuals they identify as ‘high-risk’ with guides and information of what’s available in their local area and telephone numbers they can use to get in touch with different organisations
Through sending these automated text messages and emails individuals in your targeted populated can be encouraged to be more proactive and makes changes to start their journey in improving their health and wellbeing.
2. Help deliver preventative measures
With our care needs changing and our ageing population we are seeing lots of individuals growing older with multiple different health conditions putting them at risk of living independently.
If this is your targeted population, investing in technology enabled care is a great way to deliver better proactive and preventative care to focus on the individual to delay fruture care needs and increase independence.
At Access Assure, our home hub, it makes it easy to set alerts to notify loved ones or caregivers of any changes to activity before something more critical happens. These alerts are sent in real-time to combine both reactive alarm functionality and digital insights together.
Once all sensors, smart plugs, smart alerts, are all set up Access Assure can identify patterns after 14 days, so it is easy to notify caregivers and loved ones of any subtle changes in someone’s daily life before anything critical happens.
Our Oysta offering helps to increase confidence in individuals to live more independently both inside and outside the home through providing discreet wearables to give individuals the reassurance support will always be there if they need it.
All this information is centralised in our cloud-based platform, Intellicare to ensure better joined-up care is delivered to improve outcomes and deliver effective population health management.
3. Improve the quality of care delivered
External factors and the corresponding needs of a population can change quickly as we have seen with recent events from the pandemic to the cost-of-living crisis. Having technology that can increase the visibility of a population in real time to ensure the right provisions of care are being delivered is essential to having successful population health management.
Commissioning technology is a great example of how the level of reporting and visibility needed can be applied through one system.
At Access Adam Care Commissioning, we provide the tools to help get real-time provider insights to assess if providers are delivering the right quality of care at a cost-effective rates.
Our tools also help with forecasting to ensure there is enough support available to everyone that needs it in a specific location. This can be done through recording the number of people receiving care, waiting for care, as well as what type of provision is needed.
Our provider insight team surveyed care home providers and found how sharing electronic health records (EHR) was a big burden for them. Finding a safe and compliant way to share these records was increasingly difficult and very time-consuming. However, through using commissioning software care home providers found that service users time spent on sharing records went from 3 hours per case to 1.
Our care commissioning tools at Access Adam provide sophisticated and efficient provider insights in real-time to ensure the quality, capacity, and delivery of care and support is at the best standard to tackle health inequalities to improve the health outcomes of your targeted population.
4. Improve collaborative working
As mentioned consistently throughout this article, the key to population health management being successful is through collaboratively working and sharing data with other organsiations.
But, how can data be shared across multiple organsiations safely, securely, and efficiently?
One way to do this is by using software that provides one centralised platform for all the information to be placed in. Initially, spreadsheets may be useful, however as needs of a population can be different for each individual, monitoring all their journeys can be complex, especially when you only use spreadsheets.
Our social prescribing platform at Access Elemental Social Prescribing allows you to have multi-sector partnerships working together to help build confidence in your community and eradicate any gaps in your community’s care and support services.
We can help encourage collaborative working with other organsiations further by being 100% interoperable with leading clinical systems including EMIS Web, SystmOne, and Vision, as well as our Social Care Case Management system Mosaic and our Electronic Health Record Rio. This helps local authorities, Primary Care Managers, and ICSs get the access to the data they need to identify the level of risk the individuals in your targeted population are to manage referrals better.
Equally, through improving your colloaborative working across several different organisations you can help raise awareness about the importance of both population health and social prescribing and how they work well together to deliver more personalised care to help better secure future funding.
Here our digital social prescribing software empowers Primary Care Professionals to refer patients on safe and assured pathways through our Pre-Approved Directory of Services to provide peace of mind that individuals will only ever go to services that they need, want, and to services that are safe.
5. Better data monitoring to improve outcomes further
To ensure your local authority has a platform that makes it easier to identify changes in outcomes, our analytic tools at Access Elemental Social Prescribing can provide you with the ability to link datasets together across various sector specific systems to display a bespoke dashboard to suit your goals, objectives, and your targeted population’s needs. Through this we can offer the best ways to manage your outcomes to see in real-time the impacts your services are having on your targeted population.
Our bespoke dashboards allow you to manage, measure, and manipulate your data however you wish to track your outcomes. Through doing this you can be informed of the uptake and impact of different services in your community to identify which services are better for your targeted populations, or whether they can cater to a variety of needs, as well as which services aren’t successful in tackling that specific health inequality.
Summarising the best population health management solutions
In this article we have reviewed the key difference between population health, population health management and the importance of both.
We have highlighted the processes to go through to identify not just your targeted population but their needs too and how different technological solutions can be better suited to the different health inequalities your local authority might be trying to tackle.
At The Access Group we know the need to deliver effective population health management is essential to tackle the ever-changing health inequalities we are currently facing across the UK, and how different socioeconomic factors and wider social determinants of health can impact our health physically and mentally in different ways.
We offer digital tools to help deliver better joined-up care in a variety of ways to help overcome this. Whether you need to access better provider insights in real-time, help deliver more preventative measures in your community, or a platform that can centralise all the data and information in one place, there is a variety of choice to suit your local authority’s needs.
We want to ensure you have all the information and guidance needed to use your own population health management system to improve patient's health and wellbeing even further. Watch our population health webinar today and find out more about how we can support you to get the best outcomes.
For information discover our local government software today to learn how we can help manage data and information more efficiently to help you deliver the best population health management approach that best suits your community.
Learn more about our social prescribing software and how population health approaches and social prescribing can work together to reduce health inequalities and help improve community health and wellbeing to reduce pressure across the different primary care settings in your community.
Contact us today to see first-hand how we can help you improve the health and wellbeing of your local community.
