Background: Population Health Management (PHM) is pivotal for England’s 42 Integrated Care Systems (ICSs) to transition from reactive to proactive, preventative, and person-centred care. By integrating health and social care datasets, including health determinants, ICSs aim to redesign and target services in order to use resources more effectively, improve population heath and reduce health inequalities. However, there is no agreed definition of PHM internationally [1], with scant evidence on how best to link and use historic datasets effectively in the UK [2] and Europe [1,3,4] or engage key system partners, such as primary care [5].

Approach: To support the implementation of PHM across 31 Primary Care Networks (PCN) a series of 6 multi-stakeholder Action Learning Sets were facilitated in each of the ICS’s 4 localities over a 12-month period, using a linked dataset to identify local health (service) issues to work on. The programme was evaluated by embedded researchers, utilizing systems thinking to foster innovation through real-time data analysis and feedback. Qualitative and quantitative data was collected from 25 ALSs, 16 governance meetings, 10 interviews, 4 workshops/events, 10 webinars, 1 conference, and document reviews, with 110 participants consenting to the study. Data were coded using Excel and NVIVO software.

Results: While most PHM infrastructure and resources (incentives and workforce) were established, challenges remained in PCN signup, data governance and data access issues. Resource constraints led to delays in ALS initiation, reduced support and analytical capacity and loss of momentum. All localities engaged in ALSs, identifying issues, gaining insights, and developing 6 innovations focused on vulnerable populations: children in families with a history of drug and alcohol misuse, rural male populations at risk of suicide, deprescribing of Z-drugs, and frequent attenders in primary and secondary care. Data literacy, trusting relations, use of intrinsic motivation and formal evidence facilitated those PCNs making most progress towards implementation. Engagement reached 198 individuals from health and social care, statutory and voluntary sectors, with encouraging evidence of capacity building for PHM through knowledge and relationship brokering. Involvement of patients, caregivers and community voices was largely absent.

Implications: The PHM programme demonstrated substantial engagement and conceptual understanding among stakeholders. However, challenges in infrastructure readiness, strategic integration, data governance, and resource allocation hindered full implementation, insight generation, innovation implementation and impact. Nevertheless, the evaluation highlighted the potential of PHM in improving health outcomes through strategic stakeholder collaboration and systems thinking.

References:
1. Steenkamer, B.M., et al., Defining Population Health Management: A Scoping Review of the Literature. PHM, 2016. 20(1): p. 74-85.
2. McShane, M. and K. Kirkham, Making it personal – population health management and the NHS. JIC, 2020. 28(3):243-252.
3. van Ede, A.F.T.M., et al., How to successfully implement population health management: a scoping review. BMC HSR, 2023. 23(1):910.
4. Steenkamer, B.M., et al., Implementing population health management: an international comparative study. JHOM, 2020. 34:3(1):273-294.
5. Alton, D., et al., Population health management in primary health care: a proactive approach to improve health and well-being. Primary care policy paper, 2023. World Health Organization European Region.

Background: Population growth and comorbidity are driving demand for episodic care and extended community supports creating backlogs in access, particularly for emergency care in Nova Scotia. The System Accountability Framework is designed to ensure a shared approach with clear accountabilities at all levels of leadership and operations, initially focusing on the acute care sector within three defined zones of accountability: Emergency Department, Inpatient, and Community.

Approach: The Integrated Acute & Episodic Care Clinical Services Network, with engagement from internal partners (e.g. Access & Flow Network, the Primary Health Care Network, Performance and Analytics, Research and Innovation, Continuing Care) and external partners (e.g. Emergency Health Services, Department of Health and Wellness, Department of Seniors and Long Term Care, Department of Community Services) developed and implemented a cross-sectoral Framework to help move patients through their acute care journey by identifying three clear Zones of Accountability: Community, Emergency Department and Inpatient. Network and operational teams collaborated to develop and implement shared metrics and local models and policies that can be mapped to each metric. Patient Family Advisors are integral members of the Clinical Service Networks (including the Integrated Acute & Episodic Care Network) and provide ongoing input and feedback into the design of the initiatives and policies that comprise the overall Framework. Tools included models of care, streamlining and standardizing processes, integrating Nova Scotia Governments Action for Health Initiatives, policies and reporting templates. Weekly communications and check-in meetings including operational leaders across health sectors provide an opportunity to report on progress and share early successes and opportunities for spread and scale. A dashboard and predictive modeling tool provides operational teams with line of site to weekly performance and anticipated upcoming seasonal and staffing challenges. The Framework has been integrated as a key support for a larger organizational initiative called Operational Excellence which provides structured reporting and operational grip. 

Results: Currently in week 37, implementation has already shown impact including: 50% overall reduction in 90th percentile ambulance offload times; and a 30% reduction in time to transfer. Over 8000 ambulance hours have been returned to Nova Scotia’s communities. EHS has reported a decrease in their ambulance response time over the past six months and current ambulance response times for emergency calls are averaging 20 minutes. Efforts continue to address surge capacity, through strategies and processes to improve provider response times and patient stays. This involves streamlining discharge processes for smoother patient flow.

Implications: The challenges that the System Accountability Framework aims to address are common to many health jurisdictions. This initiative demonstrates a real life implementation of the recommendations supported by the national CAEP EM-POWER report and a view to how providing a system-wide accountability framework can help teams at all levels of care, develop and implement improvements that are based on a common shared goal: each patient receives the right care at the right time in the right setting, and from the right provider. The presentation will explore challenges and opportunities related to the development and implementation of a cross-sectoral systems Framework.

Background and objectives
A key policy priority is the development of a seamless patient journeys through the continuum of health services through integrated care system reform. In this study, we learn from recent reforms in Australia, Canada, the United Kingdom) to strengthen primary care engagement in the implementation of integrated systems reforms, to gain insights from the implementation barriers and enablers at multiple levels of the system to develop implementation support programs.
Approach
We conducted a rapid jurisdictional review (Winter 2023) across five Canadian provinces (British Columbia, Alberta, Manitoba, Ontario, and Nova Scotia) and two international comparators (Australia and Scotland and England, United Kingdom). We drew from academic and grey literature about primary care delivery models and recent system reforms impacting primary care (e.g., integrated systems). We mapped our results against a conceptual framework about the sub-functions of primary care to draw out similarities, differences, innovative or promising reforms. We convened a policy dialogue (April 2024) with policymakers and local experts (n=18) from Australia (New South Wales, Victoria, and the National Aboriginal Community Controlled Health Organisation), Canada (Alberta, British Columbia, and Ontario), and England from to discuss our findings and to learn about enabling factors for the implementation of integrated systems across these jurisdictions.
Results
Primary care reform is ongoing across jurisdictions with a more recent focus on refining team-based interprofessional care and/or strengthening care pathways between physician practices and other providers/community clinics. Formal and informal studies of these reforms underscore the challenge in maintaining strong relationships between governments (payers) and primary care providers to achieve system objectives. There are notable trends related to financing and governance that may facilitate primary care reform. First, a shift away from fee-for-service (FFS) payment models toward alternative payment plans (e.g., blended capitation with some targeted incentives, a variant of pay for performance targeted at physician practice). Second, supporting collaborative approaches to primary care reform that emphasise GP buy-in and voluntary participation in new contractual models rather than a ‘command and control’ model. Third, we identify promising tools to improve accountability that governments and policy planners can use to improve how patients interact with primary care providers (e.g., family doctors, nurses) and other health providers along their care pathway. Lastly, connecting system managers and policy researchers across jurisdictions holds promise in supporting ongoing policy learning and supporting local implementation.
Conclusion
Primary care reform initiatives that shift financing away from FFS remuneration, pursue integrated care through voluntary collaboration/interprofessional teams, and promote accountability and cross-country learning are widely supported by GPs, clinician-leaders and policymakers. Our results demonstrate that further research is needed about improving partnerships and the interrelationship between primary care providers and other local community organizations responsible for implementing integrated care systems.