Population approach

What are population approaches?

Population health management describes an approach to identifying and managing the health and care risks of the local population, segmenting the risks based on needs, and designing services and other interventions to best meet these needs.

The ultimate goal of using population health management is to improve people’s care outcomes.

The approach starts with a focus on assessing the needs of a whole population in a specific geography or community. The process involves analysing locally available data to assess service needs and applying predictive modelling to estimate demand. Building a complete picture of local population needs involves combining data about health behaviours; health status; clinical care access, use and quality; and social and economic factors.

Risk stratification or segmentation tools can be used to categorise people according to different needs. There are at least four levels of increasing need:

  • People who are generally well, and who will benefit from primary prevention interventions to maintain mental, physical health and social wellbeing throughout their lives
  • People who are currently well but at risk of developing long-term conditions, i.e., they have known risk factors, and who will benefit from a targeted approach that might prevent or delay the onset of long-term conditions
  • People with long-term conditions who will benefit from early identification and treatment, personalised care planning, self-management support, medicine management and secondary prevention services to stop or delay progression to complexity, frailty or disability
  • Older people with complex needs or frailty who require a complex arrangement of integrated, holistic, personalised, coordinated care with a high degree of continuity.
  • Video transcript Open

    Population health management describes an approach to identifying and managing the health and care risks of the local population, segmenting the risks based on needs, and designing services and other interventions to best meet these needs. 

    Building a complete picture of local population needs involves combining data about:

    • health behaviours;
    • health status;
    • clinical care access,
    • use and quality of available services;
    • and social and economic factors.

    There are at least four levels of increasing need that are identified through population approaches:

    • People who are generally well, and who will benefit from prevention interventions to maintain health and wellbeing
    • People who are currently well but who can be identified as being at risk of developing long-term conditions
    • People with long-term conditions who will benefit from early interventions and secondary prevention services to stop or delay progression
    • Older people with complex needs or frailty who require a multifaceted arrangement of integrated, holistic, personalised, coordinated care with a high degree of continuity.

    Population health management requires:

    • good and standardised local data
    • effective information management systems
    • and analytic capability for segmenting population groups by different needs.

    Delivering the benefits of population health management requires a delivery system where local partnerships are in place and working well, and where services are aligned towards the local vision for integrated care.

    The emerging evidence suggests that population health management and risk stratification contribute to:

    • A reduction in the demand for hospital care, including emergency admission
    • An increase in patient satisfaction
    • And an improvement in overall health outcomes.

    In addition, population approaches ensure local resources can be efficiently targeted, supporting people at higher risk to maintain independence, and preventing or mitigating the risk of their conditions worsening.

    Population approaches are an important enabling factor in achieving the ultimate goal of integrated care: the improvement of people’s care outcomes.

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Relationship to integrated care

Population health management is used to identify the people who are most likely to benefit from integrated care as a way of keeping them well and independent, delivering the right care at home or in the community, and preventing unnecessary hospital care.

These are people who are usually older than 65, have multiple chronic conditions (multi- or co-morbidities), frequent hospital admissions and an assessment of frailty. They are likely to have a mixture of physical, psychological, cognitive and social needs.

Integrated care interventions are well suited to meeting these complex needs, which can be brought together into a personalised care and support plan. Care can be proactively managed and coordinated by a multidisciplinary team and involve a wide range of services. When urgent needs arise, a community-based nursing team can respond.

Factors associated with success

Population health management requires, first and foremost, good and standardised local data, effective information management systems, and analytic capability for segmenting population groups by different needs.

Delivering the benefits of population health management requires a delivery system where local partnerships are in place and working well, and where services are aligned towards the local vision for integrated care.

Well-coordinated and well-managed care requires:

  • an investment in staff training
  • access to shared care records or data sharing
  • consistent ways of working across professional and organisational boundaries.

Evidence of impact

The emerging evidence suggests that population health management and risk stratification contribute to:

  • reducing the demand for hospital care, including emergency department attendances, and emergency admissions and readmissions
  • increasing patient satisfaction
  • improving overall health outcomes.

In addition, population approaches ensure local resources can be efficiently targeted, supporting people at higher risk to maintain independence, and preventing or mitigating the risk of their conditions worsening.