Reaching the most vulnerable and those with higher needs through population health management

Toni Dedeu


Health and care needs across countries are changing. Societies are increasingly characterized by a growing aging population, chronic disease burden, multimorbidity and levels of disability. Likewise, the health inequality gap is becoming wider in many countries. Population health management (PHM) is being progressively adopted as countries strive to understand the range of factors that drive current and future poor health outcomes. Consequently, service planning, design and delivery, should be tailored to communities’ and people´s holistic needs and reach the most vulnerable and those with higher health and care needs.

The use of PHM at primary health care level contributes to the delivery of a proactive approach to managing the health and well-being of a given population which aims to consider its comprehensive health and social care needs, costs and outcomes. PHM pursues the achievement of 5 overall aims, namely: (i) enhancing the experience of care; (ii) improving the health and well-being of the population; (iii) reducing the per capita cost of health care and improve productivity; (iv) addressing health and care inequalities; (v) increasing the well-being and engagement of the workforce.

PHM approaches can increase the proactivity of the health system and primary health care (PHC) in particular. This has been especially relevant for PHC in enabling it to operate a dual track approach and adequately balance the response to COVID-19 while ensuring continuity of essential health services.

By making use of segmented and risk stratified patient lists, PHM can be used for a wide range of actions which include: (i) vaccine prioritization; (ii) evidence-informed prioritization of face to face versus virtual care and reaching out to those that don't present to PC providers; (iii) identification of emerging needs (at patient, community and local levels) and expansion of a tailored service accordingly; and (iv) highlighting skill mix gaps that need to be addressed by expanding the role of existing PC professionals or by adding new roles to the composition of the teams. These elements are particularly relevant to address the present and forecasted surge in long-term health and care needs due to COVID-19 pandemic.

The aim of the presentation will be to demonstrate the importance of understanding the needs of a defined population and to provide mechanisms to respond efficiently to those needs; the adoption of PHM approach and describing its pillars; and finally, to give some examples of PHM in practice.

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