Population Health Management (PHM) – undertaking the PHM cycle with High Intensity Users
PHE ePoster Library. Maclean R. 09/12/19; 274490; 50
Rebecca Maclean
Rebecca Maclean
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Abstract
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Abstract Introduction
High Intensity Users were identified as a priority area in Gloucestershire and therefore an ideal area to test & learn the PHM cycle.Method We used the PHM cycle; understanding population needs, opportunity analysis and targeting, predictive system modelling, design & implement intervention, and active monitoring & rapid improvement.
Results
Data on use from a wide range of services and providers was conducted to understand high intensity users across the system rather than for one organisation. This included data from: primary care, community services, secondary care, NHS111, out of hours and mental health. The data was then risk stratified and segmented to provide more intelligent data for evidence based intervention. This information, alongside key local assets, was provided to primary care network MDTs for review, care planning and intervention identification.
Conclusion
In summary PHM has been a strong methodology for bringing people together. The most important element are:Ensuring that PHM is understood to be the way of working across the system.Starting the PHM cycle with a clear question.Engaging stakeholders across the system to develop the methods and interventions in the most effective way.Using a clear monitoring feedback loop alongside evaluation.Improving our networks to learn from other and share our learning.Considering prevention and inequalities at every stage of the PHM cycle.Evaluation of the HIU MDT intervention is underway. External funding details
Abstract Introduction
High Intensity Users were identified as a priority area in Gloucestershire and therefore an ideal area to test & learn the PHM cycle.Method We used the PHM cycle; understanding population needs, opportunity analysis and targeting, predictive system modelling, design & implement intervention, and active monitoring & rapid improvement.
Results
Data on use from a wide range of services and providers was conducted to understand high intensity users across the system rather than for one organisation. This included data from: primary care, community services, secondary care, NHS111, out of hours and mental health. The data was then risk stratified and segmented to provide more intelligent data for evidence based intervention. This information, alongside key local assets, was provided to primary care network MDTs for review, care planning and intervention identification.
Conclusion
In summary PHM has been a strong methodology for bringing people together. The most important element are:Ensuring that PHM is understood to be the way of working across the system.Starting the PHM cycle with a clear question.Engaging stakeholders across the system to develop the methods and interventions in the most effective way.Using a clear monitoring feedback loop alongside evaluation.Improving our networks to learn from other and share our learning.Considering prevention and inequalities at every stage of the PHM cycle.Evaluation of the HIU MDT intervention is underway. External funding details
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