Population Health Management

IDC34
Version1.0.1
Type Capability
StatusEffective
Effective Date 

Full or Partial Capability status. For this Capability, Solutions are required to meet a minimum of one MUST EPIC and associated acceptance criteria but not all MUST EPICs (where there are multiple MUST EPICS) to achieve Partial Capability Status, or; to meet all MUST EPICs and their associated acceptance criteria to achieve Full Capability Status.

Description

Population Health Management is information-enabled, proactive application of strategies and interventions to defined groups of individuals to improve the health of the individuals within the group.  It is a model for helping Service Providers to assess the populations they serve across health and care.

The Population Health Management Capability supports Service Providers in accumulating and accessing healthcare data from various sources, reporting on and analysing this data, performing risk stratification and segmenting Patients/Service Users into cohorts. It also supports the setting of target outcomes for groups and the monitoring and measurement of these outcomes.

It enables Service Providers to take a comprehensive approach to uncovering gaps in care, and filling those gaps in order to provide benefits for Patients/Service Users and Service Providers by improving outcomes, aligning Health and Care Professionals, coordinating care, and optimising efficiency and revenue.


Outcomes

Organisation/Service Provider
  • Enables models of care to focus on the local population's health and care needs by identifying and analysing Patient/Service User segments
  • Ability to identify ways to improve population health by identifying Patient/Service User segment's health and social care needs, risks and health and care costs by using process metrics such as the delivery of care services, and desired outcomes
  • Supports development of practice guidelines to achieve desired outcomes for managing Patient/Service User segments
  • Enables stratification of the population to identify at-risk Patients/Service Users and enable preventive care
  • Develop and target interventions to achieve desired outcomes for Patients/Service Users segments
  • Gather outcomes and use these for analysis
Patients/Service Users
  • Receive targeted interventions, treatment or care as a result of a healthcare need being identified through analysis
Integrated and Federated Care Settings
  • Plan interventions, treatments and campaigns across the local population


MUST Epics - Epics and acceptance criteria will be evaluated during the Capability Assessment Stage of Onboarding

C34E1 - access healthcare data

As a Service Provider

I want to access accumulated healthcare data from various sources

So that I can analyse this data

Acceptance criterion 1: access healthcare data

Given the Service Provider wants to undertake health management for a population

When they have accumulated population related data

Then it can be accessed by the Solution to be used for analytics and reports



C34E2 - maintain cohorts

As a Service Provider

I want to maintain cohorts that segment my Patient/Service User population

So that I can identify interventions and strategies to support defined groups

Acceptance criterion 1: create Patient/Service User cohorts

Given the Service Provider has accumulated population related data

When the population related data is accessed by the Solution

Then Patient/Service User cohorts can be created

Acceptance criterion 2: view Patient/Service User cohorts

Given Patient/Service User cohorts exist

When the Service Provider chooses to view a Patient/Service User cohort

Then the Patient/Service User cohort is displayed

Acceptance criterion 3: amend a Patient/Service User cohort

Given Patient/Service User cohorts exist

When the Service Provider chooses to amend a Patient/Service User cohort

Then the Patient/Service User cohort can be amended

Acceptance criterion 4: delete a Patient/Service User cohort

Given Patient/Service User cohorts exist

When the Service Provider chooses to delete Patient/Service User cohorts

Then they can be deleted



C34E3 - stratify population by risk

As a Service Provider

I want to be able to stratify Patients/Service Users according to risk profile

So that I can prioritise the management of their care and define outcome targets

Acceptance criterion 1: risk stratify Patients/Service Users

Given that population related data can be accessed by the Solution

When the Service Provider chooses to stratify Patients/Service Users according to risk levels

Then risk levels are identified for Patients/Service Users

Acceptance criterion 2: assign risk level to Patients/Service Users

Given risk levels have been identified for Patients/Service Users

When the Service Provider chooses to assign risk levels to Patients/Service Users

Then risk levels can be assigned to Patients/Service Users

Acceptance criterion 3: stratify based on nationally or industry recognised algorithms

Given the Service Provider is using a Risk Stratification Tool

When there is a nationally or industry recognised algorithm for the Risk Stratification Tool

Then the Risk Stratification Tool uses the nationally or industry recognised algorithm

Acceptance criterion 4: view Risk Stratification Tool algorithm details

Given the Service Provider is using a Risk Stratification Tool

When the Service Provider chooses to view details about the algorithm used by the tool

Then the algorithm details can be viewed

And the source is displayed



C34E4 - data analysis and reporting

As a Service Provider

I want to analyse Patient/Service User data

So that I can view reports, trends and make informed decisions

Acceptance criterion 1: analyse and view reports

Given population related data can be accessed by the Solution

When the Service Provider chooses to view reports on the data based on defined search criteria

Then the results are displayed



C34E5 - outcomes

As a Service Provider

I want to be able to set, monitor and measure Patient/Service User outcomes 

So that the outcomes can be used to assess the value of changes to the co-ordination, integration and delivery of healthcare

Acceptance criterion 1: set outcome targets

Given population related data can be accessed by the Solution

When the Service Provider wants to assess the value of changes to the co-ordination, integration and delivery of healthcare

Then they can set outcome targets for Patients/Service Users 

Acceptance criterion 2: measure and monitor outcomes

Given population related data can be accessed by the Solution

When the Service Provider wants to assess the value of changes to the co-ordination, integration and delivery of healthcare

Then they can view reports to measure and monitor outcomes


MAY Epics - All May Epics and Acceptance Criteria will be evaluated during the Capability Assessment Stage of On-boarding. However, these Epics are not mandatory and will not be used as part of the overall assessment of whether the Capability is fully met. Any May Epics that are assessed as met will be available to buyers via the Buying Catalogue.

C34E6 - dashboard

As a Service Provider

I want to be able to view a tailored Population Health Management dashboard

So that I have information available to make informed decisions

Acceptance criterion 1: configure dashboard

Given the Service Provider is permitted to configure dashboards

When they choose to configure a dashboard

Then they can select the information that they would like to see on the dashboard

Acceptance criterion 2: view dashboard

Given the Service Provider has configured a dashboard

When they choose to view a dashboard

Then they can see the information that has been configured to display on the dashboard


Capability Specific Standards

Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:

None


Other Applicable Standards

Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:


Items on the Roadmap which impact or relate to this Capability

Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding