USING A POPULATION HEALTH MANAGEMENT APPROACH TO TACKLE HEALTH INEQUALITIES
10 October 2023
Areas of focus:
- Prioritising prevention and wider determinants to protect the health and wellbeing of people and communities.
- Reducing health inequalities
Why Change Was Needed
The healthcare system in Coventry and Warwickshire needed a shift from reactive to proactive care to better prevent illness, reduce hospital admissions, and address health inequalities. In Sowe Valley, high rates of Type 2 diabetes were identified, particularly among a population with significant social vulnerabilities, high deprivation, and a notable percentage of ethnic minority residents. Traditional healthcare approaches were not adequately addressing these needs, necessitating a proactive and personalised model of care.
What We Did
- Population Health Management (PHM) Approach: Health and social care professionals used PHM to design targeted interventions for Type 2 diabetes, focusing on a cohort of 170 individuals aged 20-39 with a BMI over 30.
- Personalised Care Plans: Each patient received a tailored plan and guidance from a Diabetic Nurse, with regular monitoring by a Care Coordinator to address broader health determinants.
- Holistic Family Support: The project included support for patients' families, not just individuals, emphasising integrated health and wellbeing management.
- Community Involvement: Volunteers from Compassionate Communities were paired with patients to provide additional support and encouragement.
- Data-Driven Interventions: The PHM approach used both qualitative and quantitative data to better understand and address patients' social structures, including work, family, exercise, shopping, and cooking habits.
Outcomes
- Improved Engagement: There was excellent engagement from the selected cohort, with increased awareness of available services and better self-management of their condition.
- Positive Feedback: Patients reported increased confidence in managing their diabetes, with highly positive qualitative feedback.
- Foundation for Innovation: The success of the PHM program in Sowe Valley has established a solid base for continued primary care innovation, particularly in deprived wards of Coventry.