COVENTRY AND WARWICKSHIRE TRANSFORMATION PROGRAMME
3 August 2023
Coventry and Warwickshire Primary Care Networks (PCNs) are taking part in a Population Health Management (PHM) transformation programme.
The programme is linked to the system-wide roll out of the Population Health Management Data Platform; HealtheIntent. The participating PCNs will be evaluating their local populations’ needs and choosing a cohort for which they will design interventions. The programme, which is being led by Optum, will support person-centered transformation - enabling multidisciplinary teams to use data to support proactive care delivery and then sharing lessons learned back to the system to scale and sustain progress.
Current progress
The transformation support is underway in two Places and three PCNs, enabling the application of a PHM approach aligned to local priorities. There are plans to scale out the transformation offer to more PCNs.
Coventry is focusing on proactive care. Proactive Care is an NHS Long Term Plan commitment that aims to provide proactive and personalised health and care for a targeted subset of individuals living with multiple long-term conditions, including frailty, who could benefit most, delivered through multidisciplinary teams in local communities. Unity and Navigation 1 PCNs have committed to develop and test the pilot model.
Warwickshire is focusing on diabetes. Stratford Central PCN will be utilising the Diabetes Innovation Recovery Fund to set up PCN-Specialist Virtual MDTs. The PCNs are working to ensure there is good engagement with different organisations as part of MDT working and exploring ways to engage with the relevant communities and chosen population cohorts.