Tag Archives: population health

Enhancing proactive care and population health through data analysis

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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 business.intelligence@onecare.org.uk.

Introducing population health analysis support from One Care

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One Care has launched a population health analyst support service, which aims to help primary care networks (PCNs) in Bristol, North Somerset, and South Gloucestershire (BNSSG) gain better insights into the health needs of their populations and the inequalities experienced by different patient groups.

The team provide intelligent insight to support PCNs to design and deliver appropriate services and interventions to address the identified needs.

The population health analysts at One Care also work with the wider healthcare system in making effective decisions to support general practice and the health and wellbeing of the local population.

The analysts are working on several projects, including:

  • Dashboards to support locality ageing well programmes, showing the distribution, relationships and inequalities of various priority health areas across an area (including COPD, diabetes, heart failure). The dashboards visualise overall prevalence of conditions at each practice in the locality, while also breaking them down by age, deprivation and geography to show the most affected areas
  • Sharing priority patients lists for practices across BNSSG, based on clinical risk and amenability to benefit from targeted sets of appropriate interventions, for example: vaccinations; chronic disease reviews; advanced care plans; and cancer screening.
  • Reports on cardiovascular disease, its relationship with other long-term conditions, prescribing patterns, and patient activity within the practice, with a focus on prevention and identifying gaps in existing care
  • PCN reports and priority lists of patients suffering from a combination of long-term mental and physical health challenges, to support a personalised approach to care and continuity

Rhys Lewis, head of digital at One Care, said: “General practice has a unique role in understanding the underlying causes of ill health and supporting communities to address them and drive improvement. We encourage all PCNs to get in touch with One Care’s team to collaborate on turning data into meaningful intelligence to address population health and begin to tackle inequalities.”

Each PCN in BNSSG has a dedicated One Care analyst, who can be asked to investigate specific topics or areas where clinicians feel targeted work is needed. The team is available to meet with PCNs or practices that would like to know more or make use of the service. It can be contacted via email at business.intelligence@onecare.org.uk.