Population health planning in local care partnerships

If you connect into local meetings you may hear us talk about Population Health Planning or Population Health Management. Local Care Partnerships have started using a population health management approach to tackling some of the biggest health priorities in their area. 

Population health planning is a proactive, data-driven, approach we are taking in Leeds to improve the way we provide health and care support for local people. The Kings Fund have released this handy video, which provides more information about population health management.

Some local care partnerships used population health management back in 2019 to work with people who are living with frailty. This approach allowed each partnership to see how their frail population differed from the Leeds frail population as a whole, and started conversations on how and where we should target support.

Frailty is a distinctive state of health related to the ageing process, usually characterised by a complex mix of physical, mental health and social care needs. It is a condition where the body’s in-built reserves are eroded, meaning people are vulnerable to sudden changes in their health triggered by seemingly small events, such as a minor infection or a change in medication. By combining what we know from the data with what our workforce and local people tell us, we are able to be proactive and holistic in supporting people with frailty.

This approach improves population health by data-driven planning and delivery of care to achieve maximum impact. We now use data to influence how we work with all of our different populations in Leeds. We use data modelling to identify local ‘at risk’ cohorts – and, in turn, design and target interventions to prevent ill-health and to improve care and support for people with ongoing health conditions.

The data is just the starting point in population health management. We want people to be able to live full, active lives. At the heart of this change is building different relationships with our residents, their networks and communities. This is what Local Care Partnerships are really good at.

Once we identify a group of people to work with we bring together a whole range of partners including health, care, housing, third sector and local community groups. We work with people to look at how they live their lives and how their health impacts on this. We look at what they can do to help maintain their wellbeing and identify any support they may need to help make this happen. When people need formal health and care services we also look at how we make these as joined up as possible. We want the people of Leeds to feel they have a team of people there to support them when needed rather than lots of different services to have to find their way around.

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