How to manage multimorbidity with population health management

Increasing multimorbidity across the UK means that practices must start to look for different approaches to manage growing patient needs, such as a population health management approach 

CREDIT: This is an edited version of an article that originally appeared on NHS England

In the UK multimorbidity is driving demand for healthcare services and increasing costs. More than one-in-four adults in England live with two or more conditions, and this is becoming the norm for older people and those from disadvantaged communities. 

Despite diversity in their disease profile and circumstances, people with multiple conditions frequently share common problems such as reduced mobility, chronic pain, shrinking social networks, incapacity to engage with work, and lower mental wellbeing. People with multiple conditions want greater service integration, more person-centred, holistic care, and better support for mental wellbeing. In order to address this, innovative ways of intervening are needed, such as a population health management (PHM) approach. There are steps  practices can take to help make PHM a reality.

Prioritise

Use data analysis or community stories to identify priority areas such as unwarranted high cost or high demand, or unmet need or inequality of care. The wider and richer the linked system data, the more informed this decision-making will be, but you need to get on with it using your ‘best available insights’. This can be cross-referenced to compare against similar practices and areas, such as fingertips data and joint strategic needs assessment.

Identify

Use data analysis to identify a cohort in your priority area for whom there is the best opportunity to improve the quality, efficiency or equity of care. This may include a particular condition, a group of conditions within a geographic area, a particular demographic (eg. age, ethnicity) or those at risk of a hospital or care home admission.

Understand

Use a wide lens to include the broadest range of available existing insights, and include the patient’s and carer’s voice to understand your cohort. Seeing it from the patient side will address wider determinants of health and consider health inequalities. Use this broad view to get a clear picture of existing resources and services.

Design

In designing a new model of care to deliver better outcomes, ask questions such as:

• What are the needs of the cohort?
• What outcomes do you need to see in order to meet these needs?
• What activities do you need to undertake to achieve the outcomes?
• What resources and skills do you need to invest in to engage in those activities effectively?

Implement

What was the ‘how’, ‘who’ and ‘what’ involved in making it happen? From the outset plan how you will measure the outputs and outcomes including both care provider and patient/user feedback. 

Evaluate and expand

Consider the following:

• Did you reach the target group?
• Did you achieve the intended outcomes/outputs?
• What worked well and what can you improve?
• Do you need to make any changes based on your evaluation?
• How can you scale up/share your plan?