Our population health management (PHM) tool has helped identify people with clinical and social issues across Lancashire and South Cumbria, enabling early interventions to improve health outcomes.
The PHM Segmentation Tool was developed by our business intelligence specialists to enable a place-based approach to segmenting the population based on a number of similar health and wellbeing characteristics and needs. These include wider determinants such as ethnicity, digital exclusion, housing quality and social isolation. This means they can target interventions more effectively and focus on prevention.
The tool has been built and enhanced through partnership working with clinicians and strategic PHM leads across our client geographies, as well as drawing on multi-disciplinary expertise from across MLCSU.
We have also provided analytical expertise to support integrated care systems, place-based partnerships and primary care networks with actionable insights of their population, and share best practice and relevant interventions from across our client geographies.
To date, we have helped identify and reach approximately 5,500 people with clinical and social issues, enabling Lancashire and South Cumbria Health and Care Partnership to improve health outcomes at an early stage, avoiding patients becoming unwell, reducing hospital admissions and future healthcare costs. Our insight has helped decide where best to allocate funding to address needs and health inequalities, for example:
- identifying the best location for a new community frailty service providing convenience to those most in need
- reducing violence by placing additional community support at the electoral wards with highest levels of vandalism and crime
- improving young people’s mental health by placing additional support at a list of schools with the most pupils at risk of having mental health issues
- contacting 460 individuals with previously unknown issues to ensure they had access to the services and referrals they need given their personal and clinical circumstances
- providing a list of patients with respiratory conditions who are likely to live in houses with a lack of adequate heating, which could exacerbate their condition.
Vicky Hepworth-Putt, Acting Consultant in Public Health, Cumbria County Council, said: “The PHM Tool enables me to identify clinical areas where the inequalities are widest across the area and also the wards that are outliers compared to their peers. This can help target interventions. This data can also be used strategically to target resources, although we are yet to test the success of that. The tool works well with the other PHM and PCN dashboards to provide a holistic picture of local health outcomes.”