Population Health Management

Why is it important?

Health needs are changing People are living longer, but with more years in poorer health and it is increasingly common for people to have two or more long term health conditions. We know that health is determined by an interaction between individual characteristics, lifestyle and the physical, social and economic environment – the wider determinants of health.

PHM is a methodology that enables us to deliver the outcomes set out in the Integrated Care System strategy and Joint Forward Plan. The use of PHM techniques offers a deep insight into the needs of different populations and drivers of health inequalities. Using linked data across local health and care partners, and techniques like population segmentation and risk stratification, can offer deeper insight into the holistic needs of different population groups and the drivers of health inequalities.

Embedding this approach across integrated care systems is everybody’s business and will transform the way we work and the way we care for people.

How will it be done?

Population Health Management (PHM) is about using linked data to provide new insight, and then taking linked action to improve the social, physical and mental health outcomes and wellbeing of people within and across a defined population, while reducing health inequalities. It includes segmentation, stratification and modelling to identify local ‘at risk’ cohorts – and, in turn, designing and targeting interventions to prevent ill-health and to improve care and support for people with ongoing health conditions and reducing unwarranted variations in outcomes. It actively helps to reduce health inequalities and offers proactive, targeted healthcare for every community.

What will be the outcomes?

Population health management helps us to improve the health and wellbeing of people living in South Yorkshire by using information about individual people and communities to understand local health and care needs, and how these vary for different populations. We can also use it to make sure the right services are in place to meet people’s needs now and what these might be in the future.

Population health management help our ICS to improve Population Health which is about the physical and mental health of our communities. This includes promoting wellbeing and reducing health inequalities, often linked to wider determinants of health, such as housing and education.

By understanding the needs of our population, health and care organisations working across our ICS can design, deliver and manage health and care services so they’re more joined-up and sustainable.

We can also use PHM to identify individual people with health and care needs who might benefit from specific interventions. The support received might be medical but can also be social, such as support with housing and employment, which can impact physical and mental health.

Visit the NHS website for more details on population health management.