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Step 2 – Understand

After completing an assessment of your team, the next step is to understand your population. The more you know about your practice population, the better equipped your team will be to be able to meet their needs.


On this page you will find topics on:

How can I learn about my practice population?

There are many tools available to help you know and understand your practice population. Gather data from your practice management system, PHO and, ideally, ask your patients and families directly what services and support would help them the most. You can also make use of data that has already been collected!

Once you’ve gathered your information be sure to share it with your team. Team meetings are an important aspect of quality improvement. Use the team and/or clinical meetings to review and plan actions around gaps in health care.

Read a case study to see how other practices have got to know their population.

Tips for learning about your practice population

To get started, see our tips below for getting to know your practice population using:

Gather information using query builders and population management tools

One of the key tools for understanding your practice population is regularly generating a patient register for specific conditions. This is particularly useful for high-risk, long-term conditions such as chronic lung disease, heart disease, heart failure, dementia and poorly controlled diabetes.

You can run a query builder or use population management tools to do this. Check with your PHO advisors as they can often advise what the best tools and reports for your region or practice management system are.

Both at a practice and PHO level, there will be a lot of data already collected that might be relevant such as risk stratification lists for patients thought to be at high risk of admission to hospital-based on multiple risk factors.

Use READ Codes consistently

One of the most important building blocks to improving the quality of care within a practice and being able to demonstrate how well you are doing is consistent use of READ codes within a practice and cleaning your data. 

What this means is encouraging all the doctors and nurses to use the same high-level READ codes for conditions such as diabetes and cardiovascular disease. Then check your population health tools such as Dr Info, BAPC or Karo reports or PHO reports to see how well you are doing overall as a practice.

Sometimes there are issues with screening terms mapping to the wrong place, doctors using different READ codes and others not knowing what to do. Talk with your nurse and practice advisors. They will be happy to help you sort out any remaining issues.

Once these things are sorted, you will be able to see how well you are tracking in terms of key health targets each month and talk as a team about what systems, processes, and changes can be put in place to make it easier to make sure all your eligible patients are up to date with their various disease risk assessments and management.

Make use of clinical audits

A number of clinical audits for cardiovascular disease, diabetes, COPD and dementia have been developed. These can be a useful tool for prompting a review of a particular area and are available via PHO, BPAC and the RNZCGP websites.

Understanding the impact of delivering self-management support at different stages

Both self-management support and SME can be provided for individuals and their family and whānau or in a group setting.

This summary from Health and Social Care Alliance Scotland describes these stages along with the issues for and impact of self-management.

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Anchor 2
Anchor 3
Anchor 4
Anchor 5
Anchor 6

Explore the other sections in Implementing Self-Management Support

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