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:

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…

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Health and Wellbeing Service Support

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 …

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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…

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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…

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Completed Projects

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

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…

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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…

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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…

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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 …

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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…

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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…

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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…

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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…

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