Population health management for frailty and long term conditions
Target Health Solutions (THS) helps General Practice and Integrated Neighbourhood Teams (INTs) to deliver coordinated care through proactive identification, shared assessment, and continuity across services.
We do this through a digital platform for population health management, supporting proactive identification, coordinated recall systems, shared assessment, and clinical decision support across Integrated Neighbourhood Teams.
This improves efficiency, workforce capacity, and financial sustainability for organisations while delivering better outcomes for people living with frailty and long term conditions.
Population Health Management for Long Term Conditions in General Practice
Population Health Management for Frailty in Integrated Neighbourhood Teams
Population Health Management for Frailty and long term conditions
Examples from General Practice and integrated neighbourhood teams
One coordinated encounter instead of multiple fragmented appointments
For the practice, it’s a year’s work completed in one encounter. For the patient, it’s better coordinated care.
THS’s integrated long term condition templates bring patient history, prescribing, and secondary care data into a single clinical view, supporting safer decisions, more efficient reviews, and higher quality care.
Reducing hospital admissions in frailty
THS supports population health management for frailty through software that enables:
- Earlier identification
- Risk stratification and prioritisation
- Shared digital Comprehensive Geriatric Assessment (CGA)
- Coordinated care across Integrated Neighbourhood Teams.
This helps organisations intervene earlier and support more people to remain well at home.
Smarter recall systems for long term conditions
Our integrated recall system automatically synchronises long term condition reviews, medication monitoring, safety monitoring, and other annual requirements into a single coordinated recall process. This improves efficiency, workforce capacity, patient experience, and financial sustainability across general practice.
Digital Comprehensive Geriatric Assessment (CGA) for Integrated Neighbourhood Teams
iCGA 3.0 is a digital Comprehensive Geriatric Assessment (CGA) platform that supports Integrated Neighbourhood Teams to deliver shared assessment, coordinated care planning, and continuity across organisations for older people living with frailty and dementia.
Built-in clinical alerts identify high-risk medications and poorly optimised long term conditions, supporting safer and more consistent delivery of CGA across neighbourhood teams.
Population health management dashboards for proactive care
Our Population Health Management Dashboard gives General Practice visibility across long term conditions through over 200 clinical insights, risk stratification tools, and targeted population searches.
This helps teams identify unmet need, prioritise proactive care, and focus support on the people who need it most.
Better frailty and long term identification, backed by research
THS software enables earlier identification of frailty, diabetes, hypertension, heart failure, and cardiovascular disease. This supports risk stratification and prioritisation so teams can focus proactive care on the people most at risk.
Integrated blood monitoring and results management
THS’s integrated blood monitoring templates bring together everything clinicians need for safe and efficient blood monitoring, including blood test trends, follow-up requirements, prescribing history, and recent clinical activity.
Clinicians can record decisions, manage follow-up, and communicate with patients from a single clinical view, supporting continuity and more efficient monitoring across general practice.
Tackling Health Inequalities
THS supports population health management and risk stratification across deprived and underserved populations, helping organisations target proactive care and reduce health inequalities.
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