What is population health management?
We define PHM as a collection of strategies that aims to improve the health of an entire population, using data to plan and deliver proactive care so as to maximise that population's health and wellbeing.
Effective population health managers typically build up a range of competencies and capabilities that enable this work, including cross-continuum data and analytics; robust partnerships; services focused on prevention; out-of-hospital care models; and payment models that incentivise proactive integrated care.
Based on a global review, our team found that organisations with robust PHM capabilities responded more effectively to the initial Covid-19 outbreak than those without. It turns out there's significant overlap between the capabilities necessary to control an outbreak and manage a population's health.
Dorset Integrated Care System (ICS)—which plans, purchases, and delivers health care services for a population of 803,000 in southwest England—demonstrates how PHM competencies can be leveraged both to respond to Covid-19 and build resilience.
How did Dorset use PHM to navigate Covid-19?
In 2018, Dorset—which brings together a commissioning body, local government authorities, as well as acute, community, mental health, primary care, and ambulance service providers—began developing PHM capabilities as part of its goal of keeping every person in the region healthy for longer. Below are two examples of how these PHM capabilities helped Dorset have a faster, more coordinated, and more effective response to the Covid-19 outbreak.
1. Dorset used its data warehouse to create a Covid-19 early warning system.
Prior to Covid-19, Dorset had built a 'data warehouse' with 80 primary care practices reporting data to a central repository on a 24-hour basis, merging with secondary care, community, mental health, and social care data.
When Covid-19 hit, it quickly became clear that accurate and timely data about the disease would be crucial to monitoring and controlling the outbreak locally—but this proved difficult to get ahold of.
In the absence of strong national testing data, Dorset adapted its existing data warehouse to build a Covid-19 dashboard to track other proxy measures, including ambulance call rates and primary care calls about Covid-19 symptoms. This 'soft intelligence' system enabled Dorset to effectively track potential cases, early warning signs of increasing cases in the community, and critical care capacity.
2. Dorset used existing relationships to enhance primary-secondary care collaboration.
Before the pandemic hit, Dorset had already established strong relationships between acute and primary care to improve care coordination and bolster out-of-hospital care—and these functions proved crucial this year.
In the face of Covid-19, Dorset quickly recognised it would need to rely on primary care to support more people out of the hospital to free up precious hospital space. As a first step, Dorset rapidly expanded urgent advice call lines so GPs could quickly connect to specialists. This allowed GPs to provide patients with necessary guidance without sending them to specialists for face-to-face care.
Further, Dorset established weekly calls between GP clinical leaders and acute medical directors to enhance primary-secondary care collaboration. This ensured constant two-way dialogue and has empowered primary care as leaders in an industry that has historically been dominated by acute care.
Invest in PHM now to build resilience for the future
Dorset's story provides a glimpse at a trend we saw around the world: The foundations of PHM afford systems greater resilience by providing more flexibility to adapt and respond to new or more severe needs. As the world risks entering a recession, these competencies will be even more important going forward to meet payers' demands to control costs while also improving populations' wellbeing.
If your organisation hasn't already significantly invested in PHM, the Covid-19 crisis and restoration period present a unique opportunity to forge a PHM-oriented culture and accelerate the development of the PHM capabilities crucial for future success. For guidance on how, check out our new report for four key imperatives to act on now.