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:
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 moreDiabetes 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 morePatient 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 moreWarm 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 moreActive 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 moreImproving 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 moreCompleted Projects
Take a look at some of our projects that have now been completed
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 moreOffering 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 moreOffering 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 moreOphthalmology 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 moreDigital 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 moreSmoke 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 moreIncreasing 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 moreIncreasing 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 moreIncreasing 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 moreDiabetes 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 moreIncreasing 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 moreCOVID-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 moreNHS 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? The Health Improvement and Support Team …
Learn morePriority 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…
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