As part of the Fareham and Gosport System Integrator project, NEL (working in partnership with OptiMedis Cobic, Imperial College Health Partnership, Social Finance and PPL Consulting) was tasked to develop a Population Health Management model of Fareham and Gosport patients diagnosis with, or at risk of, type 2 Diabetes. Building on existing models we identified key clinical events and observations for each patient in addition to segmenting the population by disease, demographics, co-morbidities, frailty and risk.

We helped to deliver a range of dashboards providing both, snapshot and timeline views of the patient cohort, providing flexibility to interrogate the data interactively to gain wider insights, highlighting both best and poor practice, as well as a framework for further delivery to other practices, both in Hampshire and more widely.

Although the project focused on Type 2 Diabetes Mellitus, the principles of the programme and in particular the demonstration that it is possible to undertake proactive and preventive care led by the font-line. It can be used for developing practical health care for other disease areas and population groups across whole systems, working as part of an Integrated Care System.

If you’d like to discuss this development or want more information please contact Ramesh Rajah.