Coventry and Warwickshire primary care networks will be taking part in a Population Health Management transformation programme linked to the system-wide roll-out of the Population Health Management Data Platform, HealtheIntent.
Participating PCNs will be required to evaluate their local population’s needs and choose a target cohort for designed interventions. The programme “will support person-centered transformation – enabling multidisciplinary teams to use data to support proactive care delivery and then sharing lessons learned back to the system to scale and sustain progress”.
Support is already being given to two Places and three PCNs, with plans to scale to include more PCNs in the near future.
In Coventry, the focus is on proactive care and provision of personalised health and care for a “targeted subset of individuals living with multiple long-term conditions”.
In Warwickshire, the focus is diabetes, with PCNs taking efforts to ensure “good engagement” with a variety of organisations to enable multidisciplinary working, and developing methods to engage with communities and population cohorts. One of the PCNs is to set up PCN-specialist virtual multidisciplinary teams to support this work.
SCIE’s recent webinar highlighted the need for ICSs to focus on culture change and system thinking in order to properly embed multidisciplinary working.
Last month, we covered the CQC’s announcement of its pilot for its new ICS assessment process, which will explore ““whether systems are working together to support people to access the care, support and treatment they need when they need it”.