The challenge
In March 2020 at the early stages of the COVID-19 global pandemic, Durham County Council partnered with NECS to adopt a Population Health Management (PHM) approach to support the COVID-19 response.
The challenge was to use PHM to:
- Identify patient cohorts by level of vulnerability and risk of severe COVID-19 disease and complications, as well as the indirect impacts of the social distancing and lock down measures.
- Utilise insight and intelligence to target the most vulnerable with a range of care, welfare and well-being support through the local community hub.
Our response
Integrated data: Data on clinical/medical risk was integrated with social vulnerability using unique identifiers. This enabled the creation of an integrated data set.
IG: Data sharing agreements were put in place to integrate data safely and successfully as well as to meet legal compliance across the organisations
Dashboard: Dynamic dashboards were developed in RAIDR, NECS Healthcare Intelligence Tool. The data was available to every GP practice and to the local authority who used the insights to design and coordinate their community hub, and to monitor the uptake of the support provided.
Outcomes
The NECS PHM approach identified a further 72,000 households (In addition to the centrally produced shielded patient list) containing residents who could be, socially or economically vulnerable.’ The Durham community hub were then able to reach out to their most vulnerable people to offer support during phase 1 COVID-19 response, achieving 100% initial contact with all people identified as ‘at risk or vulnerable’, resulting in 4697 people receiving government food parcels and 1,386 receiving additional local hub support.
“PHM has enabled us to undertake targeted work with our most vulnerable people and has ensured holistic interventions are in place to tackle inequalities.”