Protect NoW is tackling inequalities and improving access to health and care services through Population Health Management and risk stratification.
Population Health Management (PHM) is an approach used to improve the current and future health and well-being of people within and across a defined geographical area whilst simultaneously reducing health inequalities. It includes action to:
- Reduce the occurrence of ill health
- Deliver appropriate health and care services
- Address the wider determinants of health and their impacts.
PHM uses data from available sources to guide the planning and delivery of care to achieve maximum impact on whole population health. It includes segmentation and stratification techniques to identify those most at risk of ill health and target interventions more effectively to support prevention or the ongoing management of symptoms and ill health.
PHM methodology allows health and care systems to gain a comprehensive understanding of population health need by joining up data relating to:
- Health behaviours and status
- Clinical care access
- Use and quality of available services
- Social determinants of health (such as housing, employment and education).
Health Improvement Support Teams
Our aim is to work alongside healthcare services to tackle inequalities and to offer a wide range of health and wellbeing solutions, many of which lie beyond the reach of health and care services.
To maximise outreach, patients may be contacted via letter, text message and/or a phone call. With the aim of offering online patient intervention and potential referral to appropriate service.
All these approaches are to ensure the patient is fully aware of the reason for the contact, although calls are the preferred method to discuss and encourage patients to access relevant support to benefit their health and wellbeing. This, in turn, could prevent long term health conditions which continue to be detrimental to the patient without an intervention.
What do we do?
We call the patient to discuss the support that is available to them and the benefits that come with it. Our experience and training give us the skill set to understand and support all patient demographics. Different health pathways are available, and these are offered based on patient need.
When we identify patients at risk, owing to our duty of care, which enables us to proactively contact the patient. We then refer them to the correct pathways within the Health and Care System so the patient can obtain the most suitable support to reduce the risk.
How do we feel?
As a team, we feel confident knowing we have offered help to the patient, even if they don’t take on the support offered to them at that point, there is a sense of accomplishment knowing they have the information should they change their mind.
Our aim is always about helping the patient and getting the best outcome which meets their needs.
Since the Health Improvement Support Team has been running, we have sent out the following:
- 2,244,464 messages to promote the COVID-19 vaccination.
- 4287 patient conversations to promote and encourage patients to self-refer to the IAPT services
- a400,000 letters have been sent to patients across Norfolk and Waveney.
In 2021-2022 we achieved the following:
- The delivery of seven projects,
- We called 56243 patients in 376 days
- We identified 3864 incorrect details in the system and reported back to the practices
From April 2022 to date, we have achieved the following so far:
- Delivery of four projects
- We called 4711 patients in 49 days
- Over 1000 patients have taken up our offer of services