Health data helps deliver targeted support to at-risk people
Integrated Care Northamptonshire’s Population Health Management (PHM) programme is focused on making the best possible use of data to improve the health and wellbeing of our communities.
The programme analyses a wide range of data to understand and predict the health and care needs of vulnerable people with complex needs, working to join up services and provide support that’s tailored to their circumstances.
PHM was launched in November 2021 and has since worked with health and care colleagues across Northamptonshire to deliver a number of ‘action learning sets’. Action learning sets are small groups of professionals who meet regularly to share expertise and tackle challenges together.
One series of these action learning sets was delivered with four of our county’s Primary Care Networks (PCNs), which are local collaborations of GP practices working together to improve health and care for their populations. Each of these PCN action learning sets were given access to population health data which helped them identify groups of around 100 people with particular needs – and then develop packages of support to help them.
- MWEB PCN (Northampton, Earls Barton and Moulton) identified a group aged between 20 and 59 with a diagnosis of depression, diabetes and obesity. People in this group are being contacted individually to understand their needs and gain consent to refer them to individual or group consultations with appropriate local organisations.
- MMWF PCN (Northampton) identified a group aged between 20 and 50 with anxiety, on pain-management medication and with alcohol and/or substance abuse. People in this group are being offered one-to-one support to access local support services to address their needs.
- Grand Union PCN (Northampton) identified a group aged between 40 and 59 with hypertension, obesity and a history of smoking. People in this group are being offered help to develop personalised support plans and connected with local services who can help them.
- Red Kite PCN (Corby and Kettering) identified a group aged between 25 and 24 with a new diagnosis of depression and living in a deprived area. People in this group are being offered a one-to-one assessment to create personalised care plans, referral to appropriate services and follow-up care.
Commenting on the success of this targeted activity, one PCN action learning set participant described it as “a good way of working for the future”. Another said: “Working together has enabled us to raise awareness of different organisations and allowed meaningful involvement for improving the holistic health of the population”.