The challenge
NECS was commissioned by Humber and North Yorkshire (HNY) Integrated Care System (ICS) in June 2022 to deliver a comprehensive Population Health Management (PHM) programme across the ICS. The aim of the two-year programme was to work with Places, Local Care Partnerships and Primary Care Networks (PCNs) to use a PHM approach to help reduce existing health inequalities and improve health outcomes for the local populations.
Our response
- A structured programme of bespoke PHM facilitated workshops to support identification of population cohorts for focussed intervention to address existing health inequalities.
- Comprehensive PHM data insights packs plus analytical and interpretation support.
- Delivery of training and education sessions and resources as a menu of options to help embed a PHM approach going forward.
- Establishment of a Community of Practice to share the learning.
- Launch, mid programme and end of programme events to raise awareness, encourage engagement and to share project progress.
- Data analysis and interpretation – using techniques including the Community of 1000, segmentation and risk stratification and production of comprehensive data insight packs.
- Data management – to support patient identification for intervention.
- Delivering training and education sessions to health and social care professionals
- Large and small group facilitation, pathway mapping, service redesign, prioritisation and intervention / action planning.
- Research and evaluation – to effectively measure the impact of interventions and project outcomes.
- Project and programme management – using ISO9001 tools and techniques.
Outcomes
- 12 PCNs in four Places have participated in the programme covering a patient population of 485,180.
- 19 training sessions have been delivered to 106 people (including An Introduction to PHM, Data Analytics and Research & Evaluation).
- Four training videos have been made available for access and use.
- A Community of Practice has been established using the HNY NHS Futures platform.
- PHM Intervention Plans have been developed for the PCNs involved.
- 25 workshops have been delivered to over 234 attendees. Additional larger Place-based sessions have been delivered where requested.
- Initial results of the evaluation of the PHM programme using the NHSE PHM Maturity Matrix proforma shows that the PCNs involved in the programme have progressed from a baseline position of Emerging / Developing in their PHM knowledge, skills and capability to a current improved position of Developing / Maturing. In comparison, PCNs that did not participate in the programme remained the same as their baseline position.
“Really helpful workshops which were well steered.”