Healthy Wirral Primary and Acute Care System

Vanguard Site

Jo Goodfellow, Programme Director9th December 2015

Our new model of care

What’s our USP?

The Healthy Wirral population health management approach will be underpinned by a robust population health management platform supplied by our informatics partner who have extensive experience of working with accountable care organisations that are moving from a fee for service model to a value based model.

We will create a new care record

Focusing our approach

Information Governance

Engagement of stakeholders

High level benefits realisation

Information Governance

• Information Governance Task and Finish Group

• Working in partnership with Information Commissioners Office/HSCIC

• Development of Privacy Impact Assessment and Information Sharing Agreement

• Memorandum of Understanding

Information Governance-What did we learn?

• Constantly explore the art of the possible • We are learning too! • Cross every bridge when you come to it • Seek subject matter expert advice • Take your senior leaders with you

Stakeholder engagement

• Understanding local history and current news headlines

• Clear understanding of the change being implemented

• Stakeholder engagement strategy• Benefits analysis

High level benefits of the Population Health Management system

Benefit Type Description

Prevention Ability to stratify records distinguishing high risk, rising risk, and low risk. Interventions to prevent patient condition deteriorating

Intervention Tracking compliance to care pathway managementJoined-up care Efficient consultations through the ability to view health and social records in one place (longitudinal

record), leading to less time chasing information and improved clinical outcomes. Improved care coordination

Decision support Shared registries of patient condition groups with ability to filter and aggregate by population or organisation.

Pro-active monitoring (e.g. vital signs) to prevent deteriorating health.

Patient quality and experience

Improved communication between organisations. Reduction in duplicated tests. Reduced length of stay. Reduction in avoidable admissions and re-admissions Reduction in adverse drug interactions.

Patient self care Pro-active targeting of patient condition groups for enabling patient self care (Social Prescribing)

Population Management Opportunity to review commissioning model with improved intelligence and tracking of patient outcomes.

Opportunity for Integrated Care Co-ordination Teams that provide a responsive and person-centred approach to delivering both planned and unplanned care at home. Improve independence and wellbeing in order to avoid hospitalisation.

Where are we now?• Public engagement commences (January)• Memorandum of Understanding between

Partners (December)• Building and implementation of Diabetes and

Respiratory registries (on-going)• Commence Wellness and Depression registries

(December)• Sharing our learning and ensuring replicability

(on-going)

What matters to you?