Population Health is a vital tool for targeted direct care
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Case Finding, Interventions & Impact Analysis
Proactive healthcare requires a system that not only identifies patients most in need of support, but also implements timely interventions and tracks their effectiveness.
Without these measures, healthcare systems risk operating reactively: treating issues only after they arise rather than preventing them in the first place.
At Graphnet, our population health platform delivers an end-to-end solution that enables healthcare providers to:
· Identify patients most in need of health and care support.
· Design and implement effective interventions.
· Measure the impact of those interventions and adjust accordingly.
Identifying Patients in Need
Early intervention is critical to improving health outcomes and Graphnet’s Enhanced Case Finding Tool supports this.
By leveraging comprehensive, real-time data, the tool pinpoints individuals who would benefit from proactive care, including those with chronic conditions, high hospitalisation risk, or unmet healthcare needs.
This enables healthcare providers to rapidly identify at-risk patients at every level – from ICBs down to individual GP practices.
Targeted Healthcare Interventions
To turn insights into action, healthcare providers need the ability to plan, implement and refine interventions efficiently.
Graphnet’s Population Health Platform equips organisations with the intelligence to anticipate demand, enhance care pathways and introduce remote monitoring solutions, ensuring patients receive the right care at the right time.
Key interventions include:
· Service Planning: Anticipating surges in demand and allocating resources effectively to ensure timely care.
· Care Pathway Development: Establishing new treatment and monitoring pathways for high-risk patient cohorts, such as those with diabetes or high-risk pregnancies.
· Remote Monitoring: Graphnet’s DOC@HOME service enables suitable patients to be monitored from home, with real-time results feeding back into the Population Health Platform.
Impact Analysis: Measuring Success & Refining Strategies
For healthcare interventions to deliver meaningful and lasting change, providers need clear, data-driven insights into what works, what doesn’t and where improvements can be made.
Graphnet’s Impact Analysis Tools provide these insights, empowering healthcare teams to evaluate interventions effectively and make informed decisions. This is achieved through:
· Defining Key Metrics: Establishing measurable indicators of success such as reduction in hospital admissions, improved disease management, or increased uptake of preventative care.
· Cohort Tracking: Monitoring specific patient groups to assess the effectiveness of interventions and identify trends or disparities in outcomes.
· Interactive Dashboards: Embedding real-time analytics in user-friendly dashboards to provide healthcare teams with actionable insights that support ongoing improvement and strategic planning.
Real-World Success Stories
Data-driven healthcare isn’t just about insights - it’s about measurable impact. Across the UK, healthcare providers are using Graphnet’s Population Health solutions to drive meaningful change, from reducing smoking rates to improving chronic disease management.
Reduced Smoking Rates in Surrey
Surrey Heartlands Health and Care Partnership used Graphnet’s Case Finding Tool to assess smoking rates across East Surrey. The data revealed a significantly higher smoking prevalence in a specific, deprived location.
In response, targeted interventions such as pop-up community sessions were introduced. Over the past year, smoking prevalence in the area has dropped by 11%.
Improving Hypertension Management in Slough
By using Graphnet’s Population Health Solution, GP practices in Slough have significantly improved hypertension outcomes. The approach involved:
· Digitally led patient identification and diagnosis.
· Automated tracking of intervention outcomes.
· 75% reduction in admin time for surgery staff.
The results are particularly impressive at Ragstone Road Surgery:
· 30% increase in patients aged 79 and under with controlled blood pressure.
· 23% improvement in blood pressure control for patients aged 80 and over.
“I am incredibly proud of what we have achieved. From the outset, patient and staff feedback has been positive, engagement high, and hypertension outcomes have improved surprisingly fast. The results have been truly remarkable. We now hope this model can be adopted nationwide to improve hypertension outcomes across GP practices and primary care networks.”
- Dr Bharan Kumar, General Practitioner at Bharani Medical Centre
