One Care’s population health management (PHM) team uses data to better understand the health needs of the BNSSG patient population.
The team supports general practices to deliver targeted proactive care to specific patient groups, particularly those facing significant health disparities.
Phil Gladwin, population health analyst at One Care, worked closely with a Primary Care Network (PCN) in South Bristol to identify patients who would benefit most from personalised support.
Through analysis of health and social factors data and talking with practice clinicians, Phil identified patients with a combination of mental health issues, obesity, and diabetes who were at high risk of further ill health. Practices then contacted this group of patients to offer targeted evidence-based support.
In Yate and Frampton PCN, PHM Fellow Dr Brynn Bird developed a similar project with One Care’s PHM team.
NHS data shows spending on both diabetes care and antidepressants is significant – and has increased since before the Covid-19 pandemic – suggesting these are areas where greater support may be needed.
To identify the patient cohort with the greatest potential, the PHM team also considered other conditions including obesity and hypertension.
This data-driven approach enabled the PCN’s care coordinators to contact this patient group, inviting them for appointments and interventions designed to foster improved health outcomes.
Dr Bird said “We wanted to engage with people in the neighbourhood who are likely to suffer poor health in the long-term, due to their current mix of physical and mental health conditions and social circumstances. We were particularly interested in those who would not normally see us to help with their health, aiming to change the trajectory of their health and wellbeing.”
Providing this kind of support enables patients to better manage their health and wellbeing. The PHM service assists practices in identifying these patients, informing them about available services, and intervening before further complications develop.
Dr Bird added, “We are working with a variety of supportive people in the community, led by our health and wellbeing coach, to give those at high risk of poor health the support they need to make interventions in their own lives that are suitable for them. This is an ongoing process, and we are aiming to build on this with further presence in Yate where individuals can turn for guidance.”
These initiatives are just a few examples of how data analysis can focus healthcare provision to improve population health. If you are interested in discussing a population health management project, please email firstname.lastname@example.org.