Copyright 2019 - Clinical Commissioning Groups Association

Integrated care, system-wide intelligence and population health management - Jagwant Grewal, population health lead, Cerner UK

Fig. 1To combat the challenges faced across the NHS, integrated care and a joined-up, STP-wide approach must succeed. Commissioners are an integral component to this partnership to drive service and system redesign, and new care models.

The quadruple aim

Actionable, system-wide intelligence across the full population underpins the quadruple aim of health and care (Fig. 1). Comprehensive population health management (PHM) should impact on all of these things to shift to value-based care, better shared information and empower communities and citizens to ensure they receive the most appropriate, timely care in the right place – and improve outcomes.

We believe intelligence holds the key to creating sustainable models for healthcare optimised around the unique needs of each individual, not each venue - to create a lifetime relationship and match citizens’ unique needs to the resources in their community. It is our view that moving beyond reactive care and shifting to proactive PHM relies on three areas, knowing your population, engaging your citizens and managing their outcomes.

Know your population: Outcomes depend on having complete visibility of your citizen’s life, not just medical history, but personal devices, social, employment, behavioural, access to transportation, family history, social care issues, environmental and other dependencies.

It starts with making care data flow seamlessly. This can start with a Health Information Exchange (HIE) to help decision-making, thereby improving quality, efficiency and experience. While an important building block, the PHM journey is not simply about reacting to demand and reducing mortality in acute care. Real value and innovation will come when you have a single, system-wide source of truth that enables all stakeholders to work in partnership to reduce morbidity.

Engage citizens: Interacting and engaging with citizens on a daily basis allows you to understand them as a parent, partner, child, caregiver, professional, not just a patient.

Once you know your citizens, you can build truly personalised care plans to improve clinical outcomes, and ‘health plans’ to help improve wellbeing and quality of life. You can empower them as active members of their care team, but also engage and educate them in a specifically targeted, personalised way.

Manage outcomes: When data from all parts of the health and care economy is available, intelligence can then enable you to understand your population, including those with complex needs, or co-morbidities, and those at risk of developing these conditions. Then, underpinned by actionable insight, you can proactively address gaps in care, understand resources and capacity, identify risk, and predict opportunities to reduce morbidity, one person at a time.

Experienced and innovative partners

PHM requires us all think beyond care and be open to ‘the possibilities’. Our intelligence platform, HealtheIntent, takes in data from any source to help you deliver your health system’s vision, support you to commission services effectively and help your citizens to live longer, better. We’d love to share how we’re working with CCGs, STPs, ICSs and health systems in the UK and around the world to help them transform health and care.

Content provided by Jagwant Grewal, Cerner UK. For more information please visit

Follow Cerner on Twitter: @CernerUK

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