Population health management in local care partnerships

Some local care partnerships have started using a population health management approach to tackling some of the biggest health priorities in their area.

Population health management is a proactive, data-driven, approach we are taking in Leeds to improve the way we provide health and care support for local people. The Kings Fund have released this handy video, which provides more information about population health management.

Some local care partnerships are using population health management by working with people who are living with frailty. We want to improve the outcomes and experience for anyone in Leeds living with frailty.

Frailty is a distinctive state of health related to the ageing process, usually characterised by a complex mix of physical, mental health and social care needs. It is a condition where the body’s in-built reserves are eroded, meaning people are vulnerable to sudden changes in their health triggered by seemingly small events, such as a minor infection or a change in medication.

This approach improves population health by data-driven planning and delivery of care to achieve maximum impact. We use data modelling to identify local ‘at risk’ cohorts – and, in turn, design and target interventions to prevent ill-health and to improve care and support for people with ongoing health conditions.

The data is just the starting point in population health management. We want people to be able to live full, active lives. At the heart of this change is building different relationships with our residents, their networks and communities. Once we identify a group of people to work with we bring together a whole range of partners including health, care, housing, third sector and local community groups. We work with people to look at how they live their lives and how their health impacts on this. We look at what they can do to help maintain their wellbeing and identify any support they may need to help make this happen. When people need formal health and care services we also look at how we make these as joined up as possible. We want the people of Leeds to feel they have a team of people there to support them when needed rather than lots of different services to have to find their way around.

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