Population Health is a vital tool for targeted direct care
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Case Finding, Interventions & Impact Analysis
To make true proactive care a reality, healthcare systems need to be able to:
- Identify the patients most in need of health and care support.
- Design and implement appropriate interventions.
- Measure whether they have made a difference and tweak as and when necessary.
Our end-to-end population health system, with its rich data and in-depth insights, equips healthcare providers with all of those capabilities.
Case Finding
Graphnet's Enhanced Case Finding Tool uses comprehensive data to provide enhanced case finding at scale from ICB to practice level. This enables the rapid identification of individuals and specific groups who would benefit from early intervention for integrated and proactive care.
Interventions
The data intelligence generated by the population health platform is used to drive actions. This includes planning services such as working out what is needed, predicting when and where surges in demand are likely to come from and putting appropriate provisions in place.
Particularly important are interventions to establish new care pathways to treat and monitor target patient cohorts, such as those with or at risk of diabetes or higher-risk pregnancies.
Remote monitoring is one intervention that has been used with great success to reduce waiting lists, prevent hospital and GP visits, and keep people in the comfort of their own home. Graphnet is able to offer remote monitoring with its DOC@HOME service.
Suitable patients can be monitored at home with results flowing back into the population health platform. This provides another rich source of information for ICS analytics, and gives an even more comprehensive understanding of their citizens, their needs, and any gaps in the services that they’re providing.
Impact Analysis
Effective interventions need intelligence on what works and what doesn’t. Graphnet’s impact analysis tools provide healthcare providers with that vital information. Once the metrics associated with interventions are defined, cohorts can then be identified to monitor against, and metrics can be embedded into interactive dashboards.
Use Case: Surrey uses case finding tool to reduce smoking rates.
Surrey Heartlands Health and Care Partnership used Graphnet’s case finding tool to look at the smoking status of patients across East Surrey. They noticed that smoking had a much higher prevalence in one particular area with a high level of deprivation, and were able to organise targeted interventions and programmes, such as pop-up sessions at a local community centres. Over the past year, they have seen smoking prevalence decline by 11%.
Use Case: GP surgeries in Slough see up to 30% increase in patients with controlled blood pressure.
GP practices in Slough are achieving significantly improved hypertension outcomes following the introduction of a new, digitally led approach to identifying, diagnosing, and managing patients. Patient lists were created using Graphnet Health’s population health solution. The impact of the project was also tracked using this tool. There has been a 75% reduction in admin time for surgery staff. One GP surgery, Ragstone Road Surgery, has seen a 30% increase in patients aged 79 and under with controlled blood pressure and a 23% improvement in those 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’re now hoping that the model can be adopted and replicated across GP practices and primary care networks to improve hypertension outcomes throughout our entire region and nationwide.
Dr Bharan Kumar, General Practitioner at Bharani Medical Centre
