Population Health Management Projects

Take a look at the active Population Health Management projects currently underway, as well as our completed projects

The Population Health Management Team are currently working on the following projects.

Active Projects

Here you can learn more about the Population Health Management projects that are live across the Integrated Care system:

Maternity social prescribing pilot

Background: Health and wellbeing is so important for families expecting a baby. We know that getting the right advice, guidance and support can lead to a healthy pregnancy, birth and beyond for babies, mothers and birthing people and their wider …

Learn more

Diabetes Digital Education Programme

A pilot project has been started in Great Yarmouth and Waveney, reaching out to patients diagnosed with type 2 Diabetes via an SMS text message. They are given the offer of a digital pathway where they can self-manage their condition and reduce the …

Learn more

Patient Initiated Digital Mutual Aid System (PIDMAS)

PIDMAS is a system that can offer patients who are waiting for treatment, the choice of an alternative provider for quicker treatment where capacity is available. The aim is to reduce waiting lists in local hospitals and to clarify any specific requ…

Learn more

NHS Health Checks

Purpose: To increase uptake of the Public Health (PH) commissioned NHS Health Checks, to spot early signs of stroke, kidney disease, heart disease, type 2 diabetes and dementia. How does it work? Protect NoW Virtual Support Team will send SMS and…

Learn more

Improving Access to Psychological Therapies (IAPT) – Access to Wellbeing Service

Purpose: To increase awareness of and access to the Norfolk & Waveney Wellbeing Service (IAPT) for people experiencing mild to moderate ‘common’ mental health problems such as anxiety disorders and depression. How does it work? Seco…

Learn more

Completed Projects

Take a look at some of our projects that have now been completed

Support for People Living with Dementia

Purpose: To contact patients of participating GP Practices who are coded as living with dementia. Objective: To complete an initial triage call with the patient/and or their identified carer or person with Power of Attorney. This aims to establis…

Learn more

Proactive Falls Prevention

This project will involve Norfolk County Council contacting people who are currently receiving social care services, or those who have done so in the past, that have an increased risk of falling in the next 9 months. This will be based on a data mo…

Learn more

Warm Homes

In an effort to reduce hospital admissions due to respiratory problems, patients with respiratory conditions who are at risk of living in fuel poverty, will be targeted for financial help in order to heat their home. The ICB will provide data abo…

Learn more

Offering choice of provider for spinal surgery patients

Project overview The Protect NoW team is working with the Norfolk and Norwich University Hospital to contact 700 spinal surgery patients currently waiting for a first outpatient appointment. A new clinic has been set up in Norwich to see ensure t…

Learn more

Offering choice of provider for oculoplastic patients

Background The aim for this project was to support those who required oculoplastic surgery. The Norfolk and Norwich University Hospital were able to offer patients choice on where to have their treatment in Norwich in June 2023.   …

Learn more

Ophthalmology project

Background Norfolk and Norwich University Hospital.  Two new eye care hospitals have opened in Norwich in late 2021 providing cataract operations.   These new hospitals were accepting new referrals from GPs and optometrists and tre…

Learn more

Digital Weight Management Programme

Purpose: To increase awareness and uptake of the Digital Weight Management Programme (DWMP) in Norfolk and Waveney to support local people to manage their weight and improve their health. What is the cohort? Adults living with obesity who also ha…

Learn more

Smoke Free in Pregnancy

Background: There is a lot of information about how harmful smoking is to us all. We know it is also dangerous for unborn babies. At present Norfolk’s smoking at the time of delivery (SATOD) rate is higher than the national average. A key focus o…

Learn more

Increasing uptake of COVID-19 vaccination – reducing health inequalities and reaching underserved communities.

Protect NoW used vaccination data to make text message contact with 103,543 individuals (500,000+ SMSs) encouraging uptake / signposting to vaccination bookings and walk-in opportunities. Cohorts in scope included the Clinically Extremely Vulnerable…

Learn more

Increasing referrals to IAPT Wellbeing Services

Increasing referrals to IAPT Wellbeing Services – reducing inequalities and unwarranted clinical variation. Protect NoW identified and contacted patients who had been prescribed anti-depressants or anxiety medication by their GP, but had not acce…

Learn more

Increasing uptake of Cervical Cancer Screening – reducing inequalities and unwarranted clinical variation.

Protect NoW worked with practices to identify patients with no recorded cervical screening, or none in last 3-5 years, and most at risk through smoking and lifestyle characteristics were identified and contacted directly with an offer of support to …

Learn more

Diabetes Prevention

Diabetes Prevention – reducing inequalities and unwarranted clinical variation and increasing referrals to lifestyle change support. 15,000 pre-diabetic patients have been identified through their recent GP blood glucose results. Protect NoW cont…

Learn more

Increasing uptake of Flu Vaccination

Increasing uptake of Flu Vaccination – targeted Virtual Support Team (VST) to patients that had not been vaccinated against flu in the preceding 12 months. In response to the anticipated rise in flu in 2021 and before the COVID-19 vaccination was…

Learn more

COVID-19 Protect

COVID-19 Protect was the first large-scale Population Health Management (PHM) initiative undertaken across Norfolk and Waveney. It was nominated for six national awards in 2021 and won the Health Service Journal’s Connecting Services and Information…

Learn more

Active NoW

Purpose: To encourage patients to access exercise related support to help reduce risks associated with their clinical condition. How does it work? Patient groups are identified via the risk identification and stratification tool. Contac…

Learn more

Priority Patient Review

Priority Patient Review is designed to focus on patients with the highest reversible risk. Alerts are created based upon risk stratification using the risk identification and stratification tool system. 6 pathways have been chosen. Each pathway i…

Learn more