1. Primary care and population health management
Nav Chana, Chairman, National Association of Primary Care
Stephanie Lamb, Co-founder and Medical Director, the Well Centre

2. Primary care and population health management
Dr Nav Chana

3. The Quadruple Aim Improving the health of populations
Improving the individual experience of care
Reducing the per capita cost of care
Improving the experience of providing care
- Increasing joy and meaning for the workforce
Sikka et al (2015)BMJ Quality and Safety - 3

4. Determinants of population health outcomes

5. Value Allocative value Technical value Personal value
Muir Gray 2015 BMJ Value

6. Primary healthcare

7. Better health for all through…
Primary Healthcare
Better health for all through…
Reducing exclusion and social disparities
Organising health services around people
Integrating health into all sectors
Pursuing collaborative models
Increasing participation
WHO Definition 2008

8. Multispecialty community provision
Mental Health
Secondary care
Social
care
Community services
Primary care
Integrated provision
Appropriate ‘place’ for care delivery
Voluntary
services

9. The Primary Care Home 1
Whole population health management An integrated, multi- disciplinary workforce Financial drivers aligned with the health needs of the whole population 2 3
Focus on 30, ,000 people 4
© 2016 National Association of Primary Care

10. Population health management
A proactive  approach to managing the health and well-being of a population
Incorporates the total care needs, costs and outcomes of the population
It involves segmenting the population into groups of people with similar needs
Targeted interventions for population segments and the individuals  within.

11. Population cube Self care Informal care Generalist care
Childhood
Adulthood
Older age
Essentially well
Long Term Condition(s)
Higher Complexity need
Generalist care
Specialist care
Informal care

12. Long Term Condition(s)
Generally Well
Long Term Condition(s)
Complexity of LTC(s)
and/or Disability
Children and Young People
Working Age Adults
Older People

13. Multidisciplinary Squad with Generalist Values
Life Course
Subdivisions
Generally Well
Lower Higher
Risk Risk
Long Term Conditions
Lower Higher
Risk Risk
Complexity of LTC(s)
and/or Disability
Lower Higher
Risk Risk
Children and Young People
Neonates
Infants
Toddlers
Children
Adolescents
Working Age Adults
Young
Middle Aged
Older working age
Older People
65-80
80-90
90+
Multidisciplinary Squad with Generalist Values
Neurological (e.g. CP)
Respiratory (e.g. CF, Asthma)
Learning Disability
Mental Health Problems
Inactivity
Alcohol
Smoking
CVD
Resp. D
Cancer
Dementia
Frailty

14. Dr Stephanie Lamb

16. Integrated care
Voluntary partnership between Primary Care, voluntary sector and CAMHS.
Open for “Drop-in” 3 afternoons a week pm.
staffed by GP (adolescent health experienced), 3 youth workers and Band 7 CAMHS nurse. YP can drop in or have booked appointment.

17. Youth work outreach activities at other times
Regular counselling sessions in local schools
School assemblies and PSHE
Activities and groups – anxiety group, voice collective, Girls Group

18. Why does it matter?
80% of lifetime cannabis and alcohol use is initiated by the age of 20
50% of lifetime mental illness starts by age 15
8/10 obese teenagers become obese adults
8/10 adult smokers start as teenagers
Strong links between different risk-taking behaviours: <16 yrs who are sexually active are more likely to abuse substances

19. Remember this
70% of adult preventable deaths are the result of behaviours initiated or reinforced in adolescence.

20. And yet….. Adolescents get shorter consultations than adults …
And in the latest HBSC survey, although 80% had visited their GP in the last 12 months 48% felt uncomfortable discussing personal issues with the GP.

21. Teen Health Check
Biopsychosocial assessment based on validated HEADSSS model
Adapted for use at the Well Centre
Abridged version developed for Primary Care consultation – Emis, read coded

22. Teen Health Check Health risk factors Vulnerability
Health Inequalities

23. Well Centre Data

24. Well Centre Data

25. Well Centre Data

26. Well Centre Data