Population Health Management – Protect NoW

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 is a dynamic collaboration between NHS organisations, Local Authorities, VCSE and independent partners working across Norfolk and Waveney. We aim to tackle inequalities and to offer a wide range of health and wellbeing solutions.

The team engages with people to offer targeted support and interventions to prevent ill-health and improve health outcomes. This communication is via letter, sms and phone calls and includes detailed support of the service offered at the time of the engagement and if needed we also have the ability to explain other support available.

Our approach started in 2020, and during this time we have promoted a variety of health and social services totally 2,282,465 messages thus far.  Including covid vaccination messages with links where patients could choose sites, dates and times (if they decide  have the vaccine) and self-referral messages to services like IAPT, Digital Weight Management Programme and Health checks.

We have reached out to 94093 patients via letter and have spoken to 60k+ people and have successfully enrolled 20k+ patients in various services. We feel we have supported patients to be proactive and encouraged them to engage with the services available giving them the freedom to choose the best approach for their own individual circumstances.