Population Health Management

Our regional approach to Population Health Management (PHM) improves the health of people in our region by using data driven planning and delivery of proactive care to achieve maximum impact.

This includes segmentation, stratification and impact modelling to identify local ‘at risk’ cohorts -and, in turn, designing and targeting interventions to prevent ill-health and to improve care and support for people with ongoing health conditions and reducing variations in outcomes.

There are three core capabilities for PHM:

1. Infrastructure
2. Intelligence
3. Interventions

There are five programmes under the PHM programme which is supported by NECS:

1. Data and information governance: NECS has developed a cloud-based data access platform to provide a ‘single version of the truth’ for the region called Axym. Axym brings together a range of data sets which allow the data to be analysed for a range of purposes. It also allows users from different organisations to access data environments in a safe way so that they can use and interrogate the data.
2. Tooling: to ensure the region has a robust range of Business Intelligence tools to interrogate data and produce actionable insight. The most widely available tool for PHM analytics across the system is RAIDR which provides a platform to interrogate a range of standalone and linked datasets for health and care. RAIDR is in use across all CCGs, PCNs, Practices and some Local Authorities and Trusts across NENC and beyond. Public Health England also provide a range of tools, their two most popular are Fingertips and SHAPE.
3. Analytics: This workstream develops and delivers a range of tools, methodologies and analytical techniques to allow the identification of “at risk” patients, patient cohorts and population segments who may benefit from similar interventions. This will develop into a systematic but flexible approach to delivering actionable insight using cutting-edge analytics and will build on what NECS currently delivers to the system.
4. Workforce: This workstream will deliver an analyst workforce model that makes maximum use of and creates maximum impact from our collective analytical community.
5. Policy Direction: This work ensures that the PHM approach for the North East and North Cumbria is aligned to the emerging policy direction of NHSE/I, PHE and Local Government. This project will provide a touch point / assurance that the latest policies inform our approach.

To find out more about our approach to PHM, contact NECS
or visit their website.