Change 1: Population health management approach to identifying those most at risk

This change supports Goal 1: prevent crisis.

Making it Real statements

I am supported by people who listen carefully, so they know what matters to me and how to support me to live the life I want."

We know how to have conversations with people that explore what matters most to them – how they can achieve their goals, where and how they live, and how they can manage their health, keep safe and be part of the local community."

Tips for success

• Ensure there is a clear understanding and agreement across all partners, from the start, of what datasets are available across the system relevant to preventable hospital and long-term care admissions and how they will be used for the analysis.
• Align datasets to identify those who are frequent users of urgent and emergency care or are at risk of bed-based care. These may include people with ambulatory care sensitive conditions, urgent care sensitive conditions, increasing frailty, those with multiple long term conditions, or who are particularly socially isolated.
• Use population health assessments or joint strategic needs assessments to understand which population groups are at risk of preventable admissions, drawing on the existing knowledge and strength of partners.
• Analysis should cover demographic patterns, the effects of health and wider inequalities, and the impact of local levels of deprivation as well as admissions, activity, service and provider data and trends. Triangulate quantitative data with qualitative data, such as people’s lived experience,  care teams’ views, and feedback from staff, local Healthwatch and communities. Other relevant insights include gap analysis findings, care quality assessment, benchmarking and review recommendations. 
• With partners, agree a system-wide interpretation of the combined data and insight so there is common understanding of local trends and each partner can model risk as they address the common agreed actions. Individual partners can use this agreed interpretation as a guide, giving them flexibility to tailor their own contribution to reducing preventable admissions.
• Risk stratifi­cation should be a dynamic process. Risk levels should be re-evaluated and adjusted regularly.

Examples of emerging and developing practice

• Advancing population health management: stories from 10 areas about their different experiences of using population health management, NHS Clinical Commissioners, February 2020.
• Using data mapping to inform care decisions: ‘The Bridge’ is a data visualisation tool, designed to display public sector data and provide effective economic forecasting and market insights to inform commissioning decisions, strengthen local care provider markets and inform the development of future strategy. LGA, March 2021.
• Improving population health on the frontline – a patient’s view: A short video about a couple with type 2 diabetes who have seen benefits to their health after professionals in the Berkshire West Integrated Care System used a population health management approach to understand their issues and offer them more personalised care options, January 2020.

Supporting materials

An introduction to population health management, NHS Confederation PCN Network, 2020.

Disparities in the risk and outcomes of COVID-19, Public Health England, 2020.

Reducing avoidable emergency admissions, analysis of the impact of ambulatory care sensitive conditions in England, Dr Foster, 2019.

Population segmentation tools: ‘How to’ Guide: The BCF Technical Toolkit, Section 1, Better Care Fund, August 2014.

Proactive Care Programme: CCG support for implementation, Risk stratification tools and top tips (see Annex A), NHS England, June 2014.

Ambulatory Care Sensitive Conditions: Analysis of certain conditions for which unplanned hospitalisation may be prevented or reduced by provision of care in primary or community settings. NHS Digital, September 2020.

What are health inequalities? The King’s Fund, February 2020.

Health Inequality and the A&E Crisis, Centre for Health Economics, January 2016.

Homelessness: applying All Our Health, guide for frontline health and care staff to take action on homelessness, Public Health England, June 2019.