Moving quickly to population health management: A repeatable case study for Ireland
As Ireland considers its strategy to implement Regional Health Areas, Community Healthcare Networks and achieve Sláintecare’s goals, this case study looks at how care providers across North London partnered with Cerner to provide better care for their 1.7 million population.
North Central London Integrated Care System (NCL ICS) brings together a partnership of local health and care organisations and local councils to join up the provision of care and implement ways to improve health outcomes for residents, tackling the inequalities that currently exist. Following the publication of the NHS Long Term Plan in January 2019, North London Partners (NLP) was formed from the community of providers within the ICS, with a mission to drive integration of health and social care. This would enable population health management (PHM) across all the health and care providers within the five boroughs and the 1.68 million people of north central London.
Cerner was selected as the technology partner to assist NLP in the goal of moving away from the traditional focus on reactive care to a proactive model of care.
NLP’s background in population health
NLP is using the Cerner suite of population health management tools to help bring together and normalise data from multiple systems across the network to create an integrated, longitudinal health and care record for each of NLP’s patients. This data is being used to develop new case-finding tools, analytics and registries to identify unwarranted variation and drive gold-standard care. These tools provide insights to frontline health and care professionals, and care teams at all levels of the system, with the information subsequently used for effective targeting of interventions for individuals and populations. Currently, there are more than 1,800 health and care professionals from across north London set up as users, with more than 500 already using the analytics tool available within the platform.
Adapting and accelerating through the pandemic
The planning, collaboration and relationships already in place in support of the partnership had the benefit of enabling a more rapid and agile response once the Covid-19 pandemic hit. While the wider national effort in meeting the Covid-19 challenge focused on reaction and response to treating the infected with critical care capacity, NLP also sought to establish a proactive community-based response. In planning for this, NLP defined its priorities as:
• Providing rapid discharge for those requiring adult social care at a far greater scale and pace than ever before. Rapid two-hourly discharge turnarounds were enabled through sharing patient-level hospital data with GPs and social care workers.
• Protecting and supporting large numbers of people who were shielding across local authorities and NHS teams (this equated to about 45,000 people). The tools helped identify them and assist with getting professional support and food packages out to the vulnerable categories at a geographical level. GP practices, community and mental health providers were given access to filterable lists of registered individuals based upon the shielded lists generated by NHS Digital.
• Protecting frontline staff who were going into people’s homes where they had suspected or confirmed Covid-19. GPs, social care workers, and wider community health and care teams working within community trusts were provided with a list of at-risk patients within their populations.
• Ensuring that teams were systematically and rapidly notified when their patients/clients had been admitted to hospital or had sadly died, to help frontline health and care teams most effectively plan and deliver care.
“Population health management will remain at the heart of integrated care systems and regional population health systems far into the future. The ability to gain clearer insights into how people live, work and play within a place or neighbourhood, how this shapes health and wellbeing, and what can be done to improve outcomes will be core to the success of ICSs.”
This level of patient information was augmented by the OneLondon shared care record programme where Cerner health information exchange (HIE) technology was implemented to connect HIEs across London, including north central London’s exchange. This programme provides real-time access to the healthcare data of London’s nine million citizens, from multiple health information systems used in acute, community, mental health, and primary care. Data is patient-matched and presented back to the care provider as a single and comprehensive snapshot of each individual’s journey through the system.
Integrated care as business as usual
Beyond the Covid-19 initial response, work commenced with the onboarding of data across NLP, enabling care teams to focus on key population health priorities for their individual patients, clients and the wider communities they care. This included the development of flu and Covid vaccination analytics using HealtheIntent® to proactively support GP practices, PCNs, boroughs and the wider system in driving vaccination uptake, particularly among the most at-risk groups within the eligible cohorts, with a focus on equity across different communities.
Additional whole-life registries that have been designed and implemented include health checks for adults with serious mental illness, care quality for those living with and beyond cancer, learning disabilities, and dementia. This will facilitate further collaboration and new working practices between organisations within the NCL health economy to support population health improvements.
Population health management will remain at the heart of integrated care systems and regional population health systems far into the future. The ability to gain clearer insights into how people live, work and play within a place or neighbourhood, how this shapes health and wellbeing, and what can be done to improve outcomes will be core to the success of ICSs. It is this insight that helps to shape the services and support of the future.
Integrating care in Ireland: Cerner has worldwide experience of partnering with clients to deliver integrated care systems. We look forward to engaging with the acute, community and wider care providers – both public and private – over the coming years.
E: david.clancy@cerner.com
W: www.cerner.com/ie
Twitter: @CernerIrl
