Population Health and Population Health Management
Population Health Management can improve population health by data driven planning and delivery of proactive care to achieve maximum impact for the health and wellbeing of the population.
To do this, linked datasets are used to segment, stratify and model the local ‘at risk’ and ‘rising risk’ cohorts that in turn are used to design, target and personalize interventions to deliver proactive care and proportionate universalism to reduce health inequalities.
In Cwm Taf Morgannwg, we have successfully linked primary and secondary care data and applied population segmentation and risk stratification models to better understand our population and their needs. By grouping people in this way related to their need and use of health care services, it can help to decide how best to use limited time and resources to deliver anticipatory and preventative care.
- What is a Population Health approach?
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Being healthy is more than just not being ill. A population health approach looks to improve the physical, mental and emotional health of everyone that lives or works within Cwm Taf Morgannwg (CTM). Another important part of improving population health is to ensure that differences between groups and populations are addressed, so that everyone has an equal opportunities to grow, live, work and thrive across the whole health board.
- How is Population Health Management linked to Population Health?
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Population Health Management (PHM) supports and enables improvements in population health and is a way to proactively manage health and social care.
When implemented fully and effectively, PHM can help create the ‘golden thread’ from individual to Health Board level. This includes helping health and care professionals, such as your GP or practice Nurses, to use data to understand what is causing poor health in their local practice or cluster area to support health and care redesign – ‘right care, right time, right team’. It also enables more effective strategic planning across the whole CTM area, understanding inequality and unwarranted variation to be able to work together as a system to allocate resources to improve or manage patients’ conditions and meet their needs.
Population Health Management in CTM
The PHM Unit was established in 2021 and is based within the Public Health Team. This unit provides leadership and guidance for implementation of population health management approaches across the CTM area.
Meet the Team
Gemma Northey, Consultant in Public Health
Andrea Gartner, Principal Public Health Intelligence Analyst
Luke Midgley, Principal Public Health Practitioner
Sam Roberts, Senior Public Health Practitioner
Glenn Little, Senior Public Health Practitioner
Ciarán Slyne, Advanced Public Health Intelligence Analyst
Stella Liapi, Senior Public Health Intelligence Analyst
Maura Matthews, Senior Public Health Practitioner
Since 2021, the team have implemented a Population Segmentation and Risk Stratification (PSRS) programme that links and analyses data from primary and secondary care and applies segmentation and risk stratification models to support partners (including Primary Care Clusters, GP practices, the Frailty Service and Community Health and Wellbeing Teams) to decide how best to use limited time and resources to deliver anticipatory and preventative care for patients.