We supported Fareham and Gosport CCG develop a ‘System Integrator’ concept to enable transformation of the new models of care by overlaying the data with an evidence based population health approach which would focus on utilisation of services ensuring patients get the right care, in the right place at the right time.
Our role was to support the CCG to undertake Population Health Analytics, Care Coordination, Integrated Health (and Care) Data and provide network management.
We did this by providing analytical input to the project, working with OptiMedis Cobic, Imperial College Health Partners, PPL and Social Finance. The aim was to provide a range of analysis across diabetes, respiratory and care home using CCG Commissioning for Value Packs, Hospital Episode Statistics (HES) data and other bench-marked data from CHKS to understand the range of areas / outcomes for intervention and to identify areas of unwarranted variation. We carried out ‘deep dives’ using our Population Health and Patient Segmentation systems, working with local clinicians to demonstrate a patient pathway for specific cohorts and better understand variation in outcomes so that interventions can be better targeted.
The specific outputs from the project were:
- Risk stratification of the practice population (38,000) highlighting 1058 patients at most risk.
- Identification of various patient cohorts for review – e.g. 35 elderly patients with well managed diabetes but still on multiple medications.
- A System Integrator Implementation Guide handbook to support the CCG in scaling up to other localities and Hampshire wide.