Abstract
Background: In delivering resident-centered integrated care, it is imperative to understand our residents’ unique health needs. We present the approach adopted by Central Health, an integrated regional health network responsible for the health of a population of 1.5 million in central Singapore, to utilize diverse data sources for constructing a comprehensive population health profile, and its translation to strategy planning.
Methods: We harnessed data from multiple sources, including government statistics, national-level health surveys, and hospital electronic medical records. This integrative approach ensured a holistic understanding of our population's social determinants of health and circumvented the lack of comprehensive health and social data.
Government statistics provided data on demographic trends, and social indicators by geographical area. National-level population health survey data provided information on the population’s preventive health habits, risky behaviors and undiagnosed chronic conditions, while hospital electronic medical records contributed clinical and healthcare utilization data.
Results: We constructed a health profile of the residents living within our regional health catchment area and performed comparative analysis of areas within. We ascertained that our residents were older, experienced a higher burden of chronic diseases, and consumed more healthcare resources compared to the rest of the country. Through profiling and geospatial mapping, we also identified areas of higher need such as areas with higher burden of disease or increased utilization of public assistance for healthcare bills. These signaled a critical need for a coherent strategy to address our population’s health needs. This profile served as the cornerstone for strategic planning for our Regional Health strategy, by which three Population Health Excellence priorities were identified:
(i) Relationship-based Care: Empowering ownership of one's health through enrolment with a trusted primary care provider to anchor preventive care and support chronic care management in the community;
(ii) Place-based Care: Anchoring care with an integrated network of health and social care partners and activating residents to age well in the community; and
(iii) Integrated Care: Developing integrated care programmes using a life-journey approach that cross settings and drive value-based care for sub-populations or disease-based cohorts.
These priorities were then used to inform integrated health-social programmes and interventions across care settings. Some examples of these programs include Transitional and Home Care to cater to patients with complex needs, and Nursing Home support to address the needs of the ageing population.
Learnings: Our experience demonstrates the efficacy of utilizing multi-source data for population profiling. By synthesizing information from diverse sources, we created an understanding of our community's health landscape, which not only informed strategic planning but also ensured that our integrated care initiatives were tailored to the specific needs of our residents. Regional health systems or population health managers can adopt a similar approach in the absence of comprehensive health data.
Next steps: We are actively working on linkage and integration of data sources and are exploring the implementation of resident-level assessments through community engagements and detailed surveys, to provide a further insights of our population’s health and social needs, assets, and disparities.