Social Factors in Population Health Management

14 May 2018

Dr Lisa McNally – Director of Public Health at Bracknell Forest Council

“Population Health Management” is a concept that, if you haven’t come across it already, you soon will.  It’s the new big thing (except it’s not actually that new).

Trying to define it precisely can get messy – easily giving rise to prolonged debates and workshops that can put a real strain on supplies of flip charts and yellow sticky pads.

Here’s my stab at a definition. Population Health Management (or PHM to its friends) is about using a wide range of information on a defined population to better organise health and social care provision, thus improving the extent to which people get the right care at the right time.

It is a multifaceted approach, often using large datasets to divide people up into levels of ‘risk’ (for example, of future hospitalisation) as well as into ‘segments’ depending on their specific circumstances or needs.

“Population Health Management really needs to get out more.”

Population Health Management certainly has a noble aim.  However, in practice, it tends to be a bit too clinical and inward looking for my liking.  If it is really going to achieve the ‘triple aim’ of improved health, better patient experience and reduced costs, Population Health Management really needs to get out more.

In particular, it needs to take more from the broader definitions of “Population Health” and how it is determined. I can recommend the brilliant blogs by Greg Fell for more on this.  Most importantly, we know that Population Health is determined by a whole set of ‘upstream’, social factors that can help us better define risk and delay dependence on services.

For example, a factor that I’d like to see given more attention in Population Health Management work is social isolation.

We know that social isolation increases mortality risk by around a third as well as being consistently linked with ill health, including everything from heart disease to depression and cognitive decline.  Social isolation is also linked to excess healthcare costs, including a greater risk of delayed discharge from hospital and hospital readmission following discharge.  Indeed, the magnitude of the association with readmission is comparable to that of other important predictors, such as previous hospitalisation.

These days we do know a fair bit about assessing social isolation, and about addressing it. We know it can affect the whole population, not just older people.

So, incorporating social isolation into Population Health Management approaches really shouldn’t be too much of a stretch.  We’ll not only improve health and reduce dependence, but make our health and care systems more effective and sustainable.


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