Five capabilities for population health management

I had a careful think on this. People keep asking me on this. I definitely don’t know “the answer”, I don’t think such a thing exists. Everyone and their dog, and their dog’s dad is trying to define “population health” at the moment, hence my previous blogs on it attempting to set out my own views. In effort to further define the space, and define “standards” I had a re read of some of the stuff I’d done, another think and tried to organise in a different way to try define some core competencies.

My views are largely formed from a particular mindset and heavily influenced by Muir Gray.

Population health, population health management. What is it?

Basically an effort to describe a systematic, whole population focus to improving the management of risks in a population.

May be described by geography, by presenting health need, communities or pops of interest

but certainly not in a service orientated way. We won’t make much progress if we act with institutional approaches.

we ought to be clear and what we mean and how we organise our interventions.

Interventions might not be only clinical service delivery, they might also be service or system design, analytic or other in their nature.

We need to think about managing risk in whole populations, with actuarial thinking.

We should distinguish health and health care, or at least not conflate them.

Capability 1 – use of data linkage to get better understanding of risks and service use patterns

You’ll doubtless have seen the work a range of companies who are busy looking for business.

I like it, a lot. But it’s often nothing new.

It’s a spin on the Somerset stuff, I and a colleague (TBF my colleague did all the hard work, she knows who she is), one of my team is doing and others have done similar in previous lives. It is relatively straightforward to do if you have linked data at individual level and a bit of nouse.

The ability to do this is one of the capability of a system to do “population health”. You should think hard about whether you buy it in, or develop the skills to do it within your system.

Capability 2 – ability to predictive model

Relies on data on activity to segment. Most often using the data in risk stratification type models.

Those models are ok, if imperfect predictors of risk of xxxx happening (xxxx normally being admission in next year)

They are a little bit better predictive than clinical brain, but are NOT a replacement for clinical team

System ability to undertake predictive modelling across whole system is another core capability

Capability 3 – How to segment / what structure

Its probably not worth doing the segmentation by single disease states (aka following the WHO Burden of disease model – important tho that is) as unimorbidity is sooooo last century.

Personally I wouldn’t design segments based around the risk stratification scoring system as that’s also a bit abstract and takes us in wrong way.

Risk strat requires a lot of data.

There may be other ways to segment – eg healthy individuals, 1 LTC, 2 -3 LTC, 4+ LTC, etc….Don’t forget mental health, don’t forget LD etc…. The basic challenge is developing a population system, agnostic of provider or commissioner, that can optimise care for a population problem well described by Li et alBarnet and others. See fig 3 of Li especially.

one might equally frame it around frailty, using the EFI.

The big challenge is obviously population healthcare applied to multimorbidity. We have a good system for multi morbidity, it is called ‘general practice’. I’m not sure we have fully nailed the whole system approach to multi morbidity yet, especially one that incorporates the full spectrum of approaches across many different sectors and stakeholders

a note on various forms of risk stratification / segmentation tools as clinical tools to segment –

their predictive power is limited, they are all about equally ok (not much better than ok), they are better than clinical brain alone (see Steveton / Billings referenced elsewhere), they can’t and shouldn’t replace clinical brains, but are a tool to explain the risk in a population, and may (likely do) suffer ecological fallacy (look it up). See next blog for more detail.

Thinking wider than “health”

Can also add in stuff one might glean from other datasets. MOSAIC is oft used to draw in housing, other…..but that’s risk segmentation in a very health care delivery sense…

there ARE (as yet not that well validated) tools around risk stratification in social care.

The ability to think through this stuff critically is probably another capability.

Capability 4 – design of service response to manage risk

No point doing any form of predictive analytics and population segmentation if we don’t define and develop service models (agnostic of provider or who employs those delivering service) to manage risk  in each of those segments

Consider impactability (as per Steventon and Billings) and Patient Activation Measure or similar – method of assessing the willingness of individuals to engage.

Whole bunch of questions in this

Capability 5 – whole pop, not just those at top of risk triangle

Remember the point is down intensification of demand and shifting the demand curve leftwards. Don’t focus all energy on those at “highest risk” however that’s defined. Whole population approach needed. Read Rose and Preventive medicine

regularly reinforced by others including this uber classic by Martin Roland. Key points here

Capability to work across all segments of population needed and implement interventions that change population exposure to risk of bad stuff etc, slow complications / prevent bad things happening

DON’T forget prevention. Consider the risk factors for illness (medical model, lifestyle and social model) not just the illness! If you forget it, might as well go home now.

Other capabilities

Some of the other capabilities are described in the blogs – esp this one.

I tried to describe pop h competencies, an approach to QI in that mindset and a set of questions that one might be able to answer if you were “doing” population health in any context (need, outcomes, processes, improvement plan) –  can our system describe that for segments of the population as a whole.

Muir’s blogs are very good on this space

This pic from Muir’s website about coins it

Muir’s instruction manual is here

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