Protect NoW is tackling inequalities and improving access to health and care services through Population Health Management (PHM) and risk stratification.
It began during the pandemic to enable people particularly vulnerable to Covid-19 to access health and social support, when they needed it the most. We worked with partners across the Integrated Care System to use data to identify those most likely to benefit from help, and we then contacted those people digitally, by letter and telephone to link people to support.
We received excellent feedback from people we contacted. We helped preserve stretched resources for those who really needed it, and an evaluation found that there was an association between our support and improved clinical outcomes. We focussed particularly on contacting those in our most deprived areas, to help tackle health inequalities that had been increased by the pandemic. The success of this first project has resulted in many more projects where we have contacted tens of thousands of people to optimise their mental and/or physical health and wellbeing.
PHM: Protect-NoW Principles
Protect-NoW aims to provide PROACTIVE population health and care across Norfolk & Waveney via PHM methodology.
We care Clinically and Data led, meaning we use data sources that enable us to identify individuals with health risks quickly.
We focus on individuals that have reversible risks by trying to Prevent illness or complications.
We aim to tackle Inequalities by focusing on areas of high deprivation/poor health outcomes/specific groups with low engagement with the services
PHM and Protect-NoW Projects: How do they work?
Using a range of data sets to identify large numbers of targeted cohorts with specific risks to their health and wellbeing.
Engaging with them to offer targeted support and intervention to PREVENT ill health and future disease.
We sort the Data, meaning we can focus our efforts in geographical areas of high deprivation/poor health outcomes as well as support specific patient groups that have previously had a low ENGAGEMENT with health services.
This helps us to standardise access to health and care services and engage with those in need of INTERVENTION and support.
Protect-NoW team comprises of a virtual support team, primary care/GPs and specialists from across the health and care system – providing strategic and additional operational CAPACITY.
PHM and Protect-NoW Projects Achievements – Past, Present and Future.
Protect-NoW was launched during the COVID-19 pandemic to support individuals most vulnerable to the virus, particularly those in deprived communities facing health inequalities. By collaborating across the Integrated Care System (ICS) in Norfolk and Waveney, the initiative used data-driven methods combining healthcare, demographic, and deprivation data to identify and proactively reach people at highest risk.
Since then, Protect-NoW has delivered over 2.28 million communications, encompassing COVID-19 vaccination invitations as well as self-referral links to services including IAPT, Digital Weight Management, Health Checks, Diabetes Prevention Progamme and other initiatives with local councils. The programme’s demonstrated effectiveness in addressing health inequalities has facilitated its expansion into a wider range of health and wellbeing initiatives. By leveraging collaborative, data-driven strategies, Protect-NoW continues to play a pivotal role in enhancing Population Health outcomes.
To date, Protect-NoW has proactively reached 125,468 patients through personalized letters and engaged in direct conversations with over 82,000 individuals. Through these targeted outreach efforts, we have successfully enrolled more than 27,000 patients into a range of health and wellbeing services.
Our approach has empowered patients to take an active role in managing their health by providing clear, accessible information and encouraging them to engage with available support options. This patient focussed strategy respects individual circumstances and preferences, allowing each person the freedom to choose the services and interventions that best meet their unique needs.
We aim to continue to support patients with old and new initiatives for this next financial year.