Step 5 Practical points / Lessons learnt
Understanding Need
- Decide on how population need will be identified.
- Decide on what outcome measures will be used across the population.
- Identify data sources that illustrate the outcome measures for the defined population.
- Collate the information on population need and share across the system.
- Combine information on need with views from across the system in a transparent way to summarise the agreed need for the population.
Define the question being asked:
- Translate outputs from the population health needs assessment to define question to be answered by population health management tools.
About who? – What is the organising principle?
- Condition specific- E.g Diabetes, Obesity, HT, CRF, Osteoarthritis, Hypothyroidism
- Driven by a known effective intervention- health coach, Screening, Dietary advice
For what purpose within the system?
- Decide how the information will be used
- To inform strategic planning / system transformation / pathway development or individual care level design?- 2 year plan/ 5 year plan
- At what population geography?- Facility/Zone/Cluster
- Is it intervention led / outcome improvement led / need led?
Use this to decide of what approach to PHM is the most appropriate?
- Population Segmentation
- Risk Stratification
There are different approaches to the overall process of matching interventions with those that will benefit from them, applying various tools and techniques
- Matching interventions to known need – Truly Needs Based Approach
- Based on the outputs of needs assessment
- Start identifying those at risk or rising risk through tools such as segmentation and risk stratification
- Impactability analysis could then be undertaken to identify those most likely to benefit from interventions – either through condition related criteria or through other characteristics such as patient activation
- Matching need to known interventions- based on existing evidence based interventions but may not meet all the needs
- Following needs assessment, the system could review the known effective interventions matched to those needs
- Segmentation, risk stratification and impactability analysis could then be undertaken based on the inclusion criteria for the known interventions
Use Different approaches as above to get the right mix for PHM delivery
