Population Health Management Definition and Best Solutions

What is population health?

Population health is the process of gathering health outcomes across a population in a specific area including the distribution of these outcomes across that area. The process involves using a co-production approach with many stakeholders including the NHS, local authorities, VCSFE, and political leaders to include and consider the impacts that the wider social determinants of health can cause.

Population health outcomes can be measured in bigger or smaller groups from different geographical areas. They can be measured locally, regionally, and nationally. Population health outcomes can also be measured by various socioeconomic factors including age, gender, and ethnicity.

It is dynamic and constantly evolving, meaning that continuous learning, innovation, and evaluation methods are needed to achieve positive and sustainable outcomes.

It is argued that a population health approach is one of the top four priorities for Integrated Care Systems (ICSs) in England.

Clinicians are thought to play an important role and act as leaders to suggest wider population health interventions that would be most appropriate, practical, and relevant to a population group.

What is population health management?

Population health management is the approach where shared data is used to understand the care and support needs of the whole population so resources can be targeted and shared to those who need it.

The population health management approach allows local communities to act and tailor their services to make better use of public resources when budgets are stretched.

Different organisations will work together using historical and current data about people’s health to design new proactive models of care to improve the health and wellbeing of individuals now, and in the future to help reduce health inequalities across the country.

Why is population health management important?

Population health management is important as it allows communities to ensure more beneficial provisions are in place to best support individuals' needs to deliver better health outcomes.

Currently, 1 in 5 GP appointments are for non-clinical issues. GPs are under huge amounts of pressure therefore to reach demand and reduce waiting times. Population Health Management helps primary care and integrated care systems take a holistic approach to ensure all individuals get the support they need when they need it. This, in turn, helps individuals who need more social support receive it promptly to improve their mental health and wellbeing as well as reduce pressure on GPs.

With every in-person GP appointment costing £42 on average, through using a population health management approach GP attendance can massively reduce resulting in cost savings across several different primary care settings that can be spent in other areas to improve outcomes further.

Studies have found that loneliness and isolation can impact health to the same levels that risk factors like smoking can.

Having effective population health management is crucial therefore to help communities in several different ways including:

Encourage more person-centred care
Encourage more patient involvement
Disease Prevention
Reduce gaps in provision
Reduce GP attendance and hospital admissions and readmissions
Reduce costs

Examples of why population health management is important

To ensure Integrated Care Systems (ICS) help deliver beneficial population health management, the NHS have released examples of what good population health looks like and why it is important.

One example identified how by jointly analysing data and finding ‘at risk’ individuals, local primary networks in Blackpool were able to design new anticipatory care models. This helped social prescribing link workers and well-being practitioners connect with the right groups in the community to address the wider social determinants of health they might be suffering with.

Population health management is important therefore as it identifies where individuals in a community need help and the approach offers organisations to adapt their services to best meet their needs to improve the health and wellbeing of their service users, reduce costs, and deliver better joined-up care.

How to start the population health management process?

With the goal of population health management being to establish a cohesive approach that ensures all individuals have access to a comprehensive program to lead longer, healthier, and happier lives, having the right foundations in place is crucial.

Here are the 4 key steps to follow to ensure that population health management delivers better outcomes:

1. Define your target population or populations

This first step is vital. Without knowing what population you will be targeting you will never be able to measure its effectiveness, or understand what needs a particular population may have.

A population who is assessed as high risk will have different needs from a population with low risk and will have different needs to individuals assessed as medium risk

Also, one population might not have the same needs. If your targeted population is on a larger scale, then they may have lots of different needs and other socioeconomic factors impacting their health compared to a local level. Similarly, a targeted population that is on average older, or more economically disadvantaged will typically face different factors than a younger, more affluent population.

By defining your target population and their needs, you can solidify your population health management strategy. Here you can investigate what services have worked well for similar populations and check that your local community can deliver the care and support needed.

2. Set and measure your outcomes

Once you have defined your target population and their needs the next step in the process is to decide on the metrics used to measure your outcomes.

This may differ depending on the outcome you are trying to improve.

For example, if your targeted population is located in a more deprived area and is suffering from stress and anxiety from unstable living environments, measuring wellbeing scores after attending or receiving support could be a beneficial metric to use.

However, if your targeted population is an older generation and the aim is to provide preventative care for more vulnerable residents in an area, then measuring GP attendance and hospital admissions might be a good metric to follow.

Without understanding the outcomes, you want to measure you will be unable to identify whether your approach to improving outcomes and individuals’ health and wellbeing is successful.

3. Decide how to monitor your outcomes

For population health management to be effective there are multiple different solutions, software, and digital tools that can be used. However, not all of them will be practical depending on the population’s needs.

It is important to identify how you will record and monitor your outcomes. This will allow you to work collaboratively with other organsiations whether it’s GP practices, local councils, or support services and interventions. Through doing this outcomes can easily be monitored to spot trends and identify if the needs of a population are changing and therefore whether the approach needs adapting.

4. Review, share, and exchange results

A massive part of the population health management approach is that it only works successfully when different organsiations work together to share data and findings.

It is important that this happens consistently, this is because as population health keeps changing, and different socioeconomic factors and social determinants of health impact individuals differently over time, so do their needs.

Without sharing data and findings with other organisations in your local area your approach will never be able to evolve, progress, or grow to continue delivering better outcomes.

What is Integrated Population Health?

Integrated population health management (IPHM) refers to a comprehensive approach that combines various strategies and services to improve health outcomes across a population. This model moves beyond traditional care by integrating multiple facets of health management, including preventive care, chronic disease management, and social determinants of health. It aims to create a seamless system that addresses the diverse needs of individuals within a population through coordinated care and resources.

How does the integrated model of wellbeing in population health work?

An integrated model of wellbeing for population health builds on the principles of IPHM by emphasising a holistic view of health. This model not only focuses on physical health but also incorporates mental, emotional, and social well-being. By considering the whole person and their environment, this approach ensures that care is not fragmented but is instead part of a cohesive strategy that addresses all aspects of an individual’s health.

Integrated Population Health and social prescribing – What is the link?

Social prescribing is an essential component of the integrated model of wellbeing. It involves linking patients with non-medical services and community resources to improve their overall quality of life. For example, individuals might be referred to support groups, exercise programs, or educational workshops that complement their medical treatment. This approach aligns with integrated population health by addressing social determinants of health and enhancing overall well-being through community engagement and support.

How can technology help deliver effective population health management?

With the main part of population health management being collaborative data sharing across multiple organsiations, technology is crucial to ensure data is shared quickly, efficiently, and securely.

Without technology, the process would not work. It would take significant amounts of time and by depending on manual and paper processes there would be a risk of data being lost leading to hefty fines and reputational damage.

Through digitally transforming your processes, both different outcomes and populations can be monitored at different risk levels to easily identify where there are gaps in your approach. It will be able to show the journeys that individuals and their populations have gone on to identify if the issues you were addressing for a targeted population were successful.

What are the best population health management software solutions?

To decide which software solutions will be best for your community’s population health management approach, at The Access Group we recommend you answer these key questions to identify what help you need digitally.

Do you have a clear picture of the socioeconomic issues facing individuals in your targeted population? E.g. What is the average literacy rate? Does everyone in the population have internet access?
Do you understand the health and support resources and services currently available for the targeted population?
Have you assessed where you will get the data from and what organisations you will work with?
Have you decided how the outcomes will be assessed and monitored, or do you need more guidance?
How will you ensure all end-users will be trained to use the solutions to ensure accuracy in recording your outcomes?

By answering these key questions your local authority, Integrated Care System, or Primary Care Manager will have a clearer understanding of the type of software and solutions that will be needed to achieve your aims.

As we have discussed, throughout, every target population will have differing needs and objectives, and because of this, some software will be more effective than others.

Here are some examples of solutions and software that best suit 5 key objectives of population health management:

1. Encouraging more engagement

To ensure increased involvement from individuals of your targeted population and deliver more person-centred care many organsiations benefit from using automated communication software.

A study by HealthcareITNews stated that 46% of their respondents identified they would use some form of automated communications to deliver better population health management.

Automated communication technology can be used in a variety of ways across the different organisations your local authority may be working with:

GP Practices can send alerts to remind individuals suffering from long-term conditions they are due for their next review or need to book a blood test
VCFSE organisations and charities can send out what’s on emails to individuals in the population that sign up to the mailing list to inform individuals of the groups and support services available which could help them
Local councils can send out automated emails to individuals they identify as ‘high-risk’ with guides and information on what’s available in their local area and telephone numbers they can use to get in touch with different organisations.

Through sending these automated text messages and emails individuals in your targeted population can be encouraged to be more proactive and make changes to start their journey in improving their health and wellbeing.

2. Help deliver preventative measures

With our care needs changing and our ageing population we are seeing lots of individuals growing older with multiple different health conditions putting them at risk of living independently.

If this is your targeted population, investing in technology enabled care is a great way to deliver better proactive and preventative care to focus on the individual to delay future care needs and increase independence.

At Access Assure, our home hub, it makes it easy to set alerts to notify loved ones or caregivers of any changes to activity before something more critical happens. These alerts are sent in real-time to combine both reactive alarm functionality and digital actionable insights.

Once all sensors, smart plugs, smart alerts, are all set up Access Assure can identify patterns after 14 days, so it is easy to notify caregivers and loved ones of any subtle changes in someone’s daily life before anything critical happens.

Our Access Oysta offering helps to increase confidence in individuals to live more independently both inside and outside the home through providing discreet wearables to give individuals the reassurance support will always be there if they need it.

All this information is centralised in our cloud-based Device Management Platform, to ensure better joined-up care is delivered to improve outcomes and deliver effective population health management.

3. Improve the quality of care delivered

External factors and the corresponding needs of a population can change quickly as we have seen with recent events from the pandemic to the cost-of-living crisis. Having technology that can increase the visibility of a population in real-time to ensure the right provisions of care are being delivered is essential to having successful population health management.

Commissioning technology is a great example of how the level of reporting and visibility needed can be applied through one system.

At Access Adam Care Commissioning, we provide the tools to help get real-time provider insights to assess if providers are delivering the right quality of care at cost-effective rates.

Our tools also help with forecasting to ensure there is enough support available to everyone who needs it in a specific location. This can be done through recording the number of people receiving care, and waiting for care, as well as what type of provision is needed.

Our provider insight team surveyed care home providers and found how sharing electronic health records (EHR) was a big burden for them. Finding a safe and compliant way to share these records was increasingly difficult and very time-consuming. However, through using commissioning software care home providers found that service users' time spent on sharing records went from 3 hours per case to 1.

Our care commissioning tools at Access Adam provide sophisticated and efficient provider insights in real-time to ensure the quality, capacity, and delivery of care and support are at the best standard to tackle health inequalities to improve the health outcomes of your targeted population.

4. Improve collaborative working

As mentioned consistently throughout this article, the key to population health management being successful is through collaboratively working and sharing data with other organsiations.

But, how can data be shared across multiple organsiations safely, securely, and efficiently?

One way to do this is by using software that provides one centralised platform for all the information to be placed in. Initially, spreadsheets may be useful, however as the needs of a population can be different for each individual, monitoring all their journeys can be complex, especially when you only use spreadsheets.

Our social prescribing platform at Access Elemental Social Prescribing allows you to have multi-sector partnerships working together to help build confidence in your community and eradicate any gaps in your community’s care and support services.

We can help encourage collaborative working with other organsiations further by being 100% interoperable with leading clinical systems including EMIS Web, SystmOne, and Vision, as well as our Social Care Case Management system Mosaic and our Electronic Health Record Rio. This helps local authorities, Primary Care Managers, and ICSs get the access to the data they need to identify the level of risk the individuals in your targeted population are to manage referrals better.

Equally, through improving your collaborative working across several different organisations you can help raise awareness about the importance of both population health and social prescribing and how they work well together to deliver more personalised care to help better secure future funding.

Here our digital social prescribing software empowers Primary Care Professionals to refer patients on safe and assured pathways through our Pre-Approved Directory of Services to provide provide peace of mind that individuals will only ever go to services that they need, want, and to safe services.

5. Better data monitoring to improve outcomes further

To ensure your local authority has a platform that makes it easier to identify changes in outcomes, our analytic tools at Access Elemental Social Prescribing can provide you with the ability to link datasets together across various sector-specific systems to display a bespoke dashboard to suit your goals, objectives, and your targeted population’s needs. Through this, we can offer the best ways to manage your outcomes to see in real-time the impacts your services are having on your targeted population.

Our bespoke dashboards allow you to manage, measure, and manipulate your data however you wish to track your outcomes. Through doing this you can be informed of the uptake and impact of different services in your community to identify which services are better for your targeted populations, or whether they can cater to a variety of needs, as well as which services aren’t successful in tackling that specific health inequality.

Summarising the best population health management solutions

In this article we have reviewed the key difference between population health, population health management and the importance of both.

We have highlighted the processes to go through to identify not just your targeted population but their needs too and how different technological solutions can be better suited to the different health inequalities your local authority might be trying to tackle.

We have also addressed the differences between population health and integrated population health and what is needed to make that step.

At The Access Group we know the need to deliver effective population health management is essential to tackle the ever-changing health inequalities we are currently facing across the UK, and how different socioeconomic factors and wider social determinants of health can impact our health physically and mentally in different ways.

We offer digital tools to help deliver better joined-up care in a variety of ways to help overcome this. Whether you need to access better provider insights in real-time, help deliver more preventative measures in your community, or a platform that can centralise all the data and information in one place, there is a variety of choice to suit your local authority’s needs.

We want to ensure you have all the information and guidance needed to use your population health management system to improve patient's health and wellbeing even further. Watch our population health webinar today and find out more about how we can support you to get the best outcomes.

For information discover our local government software today to learn how we can help manage data and information more efficiently to help you deliver the best population health management approach that best suits your community.

Learn more about our social prescribing software and how population health approaches and social prescribing can work together to reduce health inequalities and help improve community health and wellbeing.