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Care Management Platforms For Population Health

Care Management Platforms for Population Health

Treating diseases is what the traditional understanding of medicine is all about. But awareness grows that diseases have causes, and that these causes cannot only be found in the genome or in the individual behaviour, but also in the social surrounding of a person.

“If we aim for comprehensive care, we need tools that help us to provide a more holistic picture of the health of patients or indeed citizens”, said Rob Havasy, managing irector of the Personal Connected Health Alliance (PCHA).

During a session on the integration of health and social care at this year’s HIMSS & Health 2.0 Europe Conference, several examples were discussed of regions in the UK and in Finland that have decided to take population health seriously and to establish digital platforms in order to better coordinate both treatment effort and prevention activities.

The borough of Southwark in Central London, for example, has embarked on a project called Partnership Southwark that aims at establishing an integrated care system in a part of town that is highly ethnically diverse and in which, among other problems, mental health, dementia/frailty, and childhood obesity urgently need to be tackled.

To do so, Southwark with its 310,000 inhabitants was creating neighbourhoods with 30,000 to 50,000 inhabitants each, said professor Kevin Fenton, director of public health at though of Southwark. In these neighbourhoods, platform-like primary care structures are currently being established that bring together GPs, therapists of all kind, and social workers. They agree on a joint leadership team, define outcome measures for various health priorities and develop specific services that are then rolled out across the neighbourhoods.

That a digital platform can be very helpful for this kind of endeavour was illustrated by Dr. Masood Nazir, CCIO at the NHS Birmingham, a trust that has recently and successfully gone through the EMRAM Continuity of Care Maturity Model assessment of HIMSS Analytics. At the core of the Birmingham integrated care efforts is a digital platform that – after asking citizens and patients – was called ‘YourCareConnected’. It allows nurses, doctors and other healthcare professionals to share patient data and access GP records.

Specific “tabs” have been created for distinct care situations, for example a ‘Supportive Care Tab’ for end of life care which allows citizens to specify what kind of care they wish and don’t wish in case of a terminal illness. Nazir said that in the beginning, social care workers were not included into the platform because many citizens were not convinced that they should have access to healthcare data. With increasing levels of trust into the platform and its usefulness, this could change, though, and social care could become an important part of the integrated care platform in Birmingham.

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