{"id":860,"date":"2022-11-29T15:12:06","date_gmt":"2022-11-29T15:12:06","guid":{"rendered":"https:\/\/bnssghealthiertogether.org.uk\/?page_id=860"},"modified":"2025-08-15T11:05:15","modified_gmt":"2025-08-15T10:05:15","slug":"population-health-management","status":"publish","type":"page","link":"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/population-health-management\/","title":{"rendered":"Menaxhimi i Sh\u00ebndetit t\u00eb Popullsis\u00eb"},"content":{"rendered":"<div class=\"assembler_default-group assembler_module_group assembler_default-group_1 assembler_module_group_1\"><div class=\"assembler_module_area assembler_module_area_1\"><div class=\"assembler_table-of-contents-module assembler_module assembler_table-of-contents-module_1 assembler_module_1  transparent\"><a tabindex=\"-1\" title=\"Section titled module-1\" id=\"module-1\" href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/#module-1\" class=\"anchor\"><span class=\"hidden\">Section titled module-1<\/span><\/a><!-- Template found for table-of-contents-module - Template: template-table-of-contents - Matched: _only -->\r\n<section class=\"w-full mx-auto max-w-content border-b border-pale-grey pt-6 sm:pt-12 pb-3 sm:pb-6\">\r\n    <div class=\"entry-content w-full\">\r\n    <h1>Knowledge hub<\/h1>\n<p>Contents<\/p>\n    <div class=\"navigation-list\">\r\n                    <ul>\r\n                      <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                Knowledge hub                                <\/a>\r\n                          <\/li>\r\n                                <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/system-outcomes-framework\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                System outcomes framework                                <\/a>\r\n                          <\/li>\r\n                      <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/health-inequalities\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                Health inequalities                                <\/a>\r\n                          <\/li>\r\n                      <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/public-health-intelligence\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                Population Health Intelligence                                <\/a>\r\n                          <\/li>\r\n                      <li class=\"text-sm\">\r\n                                                              Population Health Management                            <\/li>\r\n                      <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/research-evidence-and-evaluation\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                Research, evidence and evaluation                                <\/a>\r\n                          <\/li>\r\n                      <li class=\"text-sm\">\r\n                              <a href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/population-health-intelligence-resource-portal\/\" class=\"text-sm underline-offset-4 font-normal hover:!underline-4\">\r\n                                                                Population Health Intelligence Resource Portal                                <\/a>\r\n                          <\/li>\r\n                  <\/ul>\r\n          <\/div>\r\n  <\/div>\r\n<\/section><\/div><!-- .assembler_table-of-contents-module.assembler_module.assembler_table-of-contents-module_1.assembler_module_1..transparent --><div class=\"assembler_text-module assembler_module assembler_text-module_2 assembler_module_2  transparent\"><a tabindex=\"-1\" title=\"Section titled module-2\" id=\"module-2\" href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/#module-2\" class=\"anchor\"><span class=\"hidden\">Section titled module-2<\/span><\/a><!-- Template found for text-module - Template: template-text - Matched: _only --><section class=\"w-full mx-auto max-w-content pt-6 sm:pt-12 pb-3 sm:pb-6\">\r\n  <div class=\"entry-content w-full !px-0 max-w-small\">\r\n        <h1>Population Health Management<\/h1>\n<p>Population Health Management (PHM) is the way we work together to understand and improve the health of people and communities using joined-up health and social care records.<\/p>\n<p>A core objective for our Integrated Care System is improving population health. By this we mean improving health outcomes, promoting wellbeing, and reducing inequalities across our entire population. Population health management is one of the key enablers for achieving this.<\/p>\n<h2>How does it work?<\/h2>\n<p>We bring together records from General Practice, hospitals, mental health providers, community services, social care, and other sources. This helps us build a better understanding of people\u2019s health, the circumstances in which they live, their needs, and the type of care they receive.<\/p>\n<p>We use this data, alongside other valuable sources of information such as from our citizens through surveys and focus groups or research evidence, to develop \u2019actionable insights\u2019 \u2013 i.e. something we can use to make a positive change.<\/p>\n<h2><strong>System-wide dataset<\/strong><\/h2>\n<p>The Bristol, North Somerset and South Gloucestershire system-wide dataset is a patient-level dataset that links together information across Primary Care, Secondary Care, Mental Health and Community Services for everyone in our region (who have not opted out).<\/p>\n<p>The dataset consists of two tables \u2013 attributes and activity. The first table contains information regarding patient characteristics, such as demographic information (age and sex), clinical information (long term conditions), socio-economic information (deprivation index) as well as other data like smoking status and social status. The second table contains information regarding patient contacts such as point of delivery (e.g. secondary care, inpatient, elective), specialty (e.g. dermatology), provider, dates, times and cost.<\/p>\n<p>This dataset is a key enabler to furthering insight-driven and value-based healthcare across Bristol, North Somerset, and South Gloucestershire.<\/p>\n<p>By linking data we can understand more about how people with different needs interact with the various healthcare services, and identify opportunities to improve and better co-ordinate the delivery of healthcare across our region.<\/p>\n      <a href=\"https:\/\/bnssghealthiertogether.org.uk\/wp-content\/uploads\/2022\/11\/SWD-Guide.xlsx\"  class=\"btn-link flex w-[fit-content] \">System-wide dataset guide<\/a>\n\n<p>For more information about the Bristol, North Somerset and South Gloucestershire system-wide dataset contact <a href=\"mailto:bnssg.analytics@nhs.net\">bnssg.analytics@nhs.net<\/a>.<\/p>\n<p>To read more on this topic from Dr Richard Wood, head of Modelling and Analytics, NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board (ICB), please see <a href=\"https:\/\/www.hsj.co.uk\/technology-and-innovation\/linked-datasets-need-not-be-the-preserve-of-the-rich\/7026353.article\" rel=\"noopener\">Richard\u2019s most recent blog post<\/a>.<\/p>\n  <\/div>\r\n  <\/section><\/div><!-- .assembler_text-module.assembler_module.assembler_text-module_2.assembler_module_2..transparent --><div class=\"assembler_text-module assembler_module assembler_text-module_3 assembler_module_3  transparent\"><a tabindex=\"-1\" title=\"Section titled module-3\" id=\"module-3\" href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/#module-3\" class=\"anchor\"><span class=\"hidden\">Section titled module-3<\/span><\/a><!-- Template found for text-module - Template: template-text - Matched: _only --><section class=\"w-full mx-auto max-w-content pt-3 sm:pt-6 pb-3 sm:pb-6\">\r\n  <div class=\"entry-content w-full !px-0 max-w-small\">\r\n        <h2>Projects using the dataset<\/h2>\n      <a href=\"https:\/\/bnssghealthiertogether.org.uk\/knowledge-hub\/population-health-management\/current-projects\/\" class=\"btn-link flex w-[fit-content] \">Current Projects using the Bristol, North Somerset and South Gloucestershire Dataset<\/a>\n\n      <a href=\"https:\/\/bnssghealthiertogether.org.uk\/knowledge-hub\/population-health-management\/completed-projects\/\" class=\"btn-link flex w-[fit-content] \">Completed projects using the Bristol, North Somerset and South Gloucestershire system-wide dataset<\/a>\n\n  <\/div>\r\n  <\/section><\/div><!-- .assembler_text-module.assembler_module.assembler_text-module_3.assembler_module_3..transparent --><div class=\"assembler_text-module assembler_module assembler_text-module_4 assembler_module_4  transparent\"><a tabindex=\"-1\" title=\"Section titled module-4\" id=\"module-4\" href=\"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/#module-4\" class=\"anchor\"><span class=\"hidden\">Section titled module-4<\/span><\/a><!-- Template found for text-module - Template: template-text - Matched: _only --><section class=\"w-full mx-auto max-w-content pt-3 sm:pt-6 pb-10 sm:pb-20\">\r\n  <div class=\"entry-content w-full !px-0 max-w-small\">\r\n        <h2>Working with you<\/h2>\n<p>Here are some examples of how we have been using Population Health Management to improve the health and wellbeing of our population.<\/p>\n<h3><strong>Case study: Healthy Hearts group<\/strong><\/h3>\n<p>Linett was part of a group of 100 people living in Bristol Inner City who were identified as being at risk of heart failure. Linett and the group were offered a range of support options. This included attending a Healthy Hearts group, where people met with specialists and peers to discuss health issues and find personalised solutions. Through this group, support from a nurse, a dietician, a physio, and a social prescriber was provided.<\/p>\n<div class=\"embed_wrapper\"><iframe title=\"Improving Population Health on the front line \u2013 a Healthy Hearts group intervention\" width=\"640\" height=\"360\" src=\"https:\/\/www.youtube.com\/embed\/v5Nt0_dwths?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/div>\n<p>More information about this case study can be found on the\u00a0<a href=\"https:\/\/www.england.nhs.uk\/integratedcare\/resources\/case-studies\/drive-to-find-vulnerable-groups-helps-100-at-risk-of-heart-failure\/\" rel=\"noopener\"><strong>NHS England website<\/strong><\/a>.<\/p>\n<h3><strong>Case study: Covid-19 pandemic<\/strong><\/h3>\n<p>Dr Charlie Kenward explains how population health management was used during the Covid-19 pandemic.<\/p>\n<div class=\"embed_wrapper\"><iframe title=\"CCG AGM 2021: Population Health Management\" width=\"640\" height=\"360\" src=\"https:\/\/www.youtube.com\/embed\/Rnl4MlusWWo?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/div>\n<p>&nbsp;<\/p>\n  <\/div>\r\n  <\/section><\/div><!-- .assembler_text-module.assembler_module.assembler_text-module_4.assembler_module_4..transparent --><\/div><!-- .assembler_module_area.assembler_module_area_1 --><\/div><!-- .assembler_default-group.assembler_module_group.assembler_default-group_1.assembler_module_group_1  -->","protected":false},"excerpt":{"rendered":"<p>Information about a patient-level dataset that links together information across Primary Care, Secondary Care, Mental Health and Community Services for everyone in our region (who have not opted out).<\/p>","protected":false},"author":7,"featured_media":0,"parent":9934,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"tags":[909,914,916,915],"class_list":["post-860","page","type-page","status-publish","hentry","tag-data","tag-dataset","tag-insights","tag-record-of-processing"],"acf":[],"_links":{"self":[{"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/comments?post=860"}],"version-history":[{"count":26,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/revisions"}],"predecessor-version":[{"id":41824,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/860\/revisions\/41824"}],"up":[{"embeddable":true,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/pages\/9934"}],"wp:attachment":[{"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/media?parent=860"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/bnssghealthiertogether.org.uk\/sq\/wp-json\/wp\/v2\/tags?post=860"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}