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.

See THS in practice

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

Integrated long term condition review system showing diabetes monitoring, care processes, biomarkers, clinical coding, and longitudinal review information within a single coordinated clinical view.

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.

Chart showing a 25.4% reduction in A&E attendances for people aged 75+ following implementation of THS software supporting frailty identification, risk stratification, and digital CGA across Integrated Neighbourhood Teams.

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.

Integrated recall system showing synchronised long term condition reviews, blood monitoring, medication safety checks, and annual care requirements within a single coordinated General Practice review process.

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.

Integrated Neighbourhood Team using digital Comprehensive Geriatric Assessment (CGA) software to support coordinated frailty care, shared assessment, and multidisciplinary decision-making.

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.