Over the last few years, using a Population Health Management (PHM) framework, we have successfully implemented two bespoke projects aimed at improving patient well-being, reducing GP appointment volumes, and preventing falls within our local community.
Project 3: Reducing GP Attendance Through Targeted Health Checks
This project focused on identifying patients with exceptionally high GP attendance rates—over double the national average. We aimed to understand and address the underlying causes through at-home health checks and social prescribing.
- 105 patients were identified and invited to participate.
- 66% accepted the initial offer of support.
- 43% completed two health checks over 12 months.
- 76% of participating patients showed a reduction in GP appointments after receiving support.
By addressing unmet health and social care needs, this initiative helped ease pressure on GP services while ensuring patients received the right care in the right setting.
Project 4: Falls Prevention and Strength & Balance Support
This project targeted patients at risk of falls, offering a comprehensive Falls Prevention Package, which included:
✅ A full health check
✅ A medication review
✅ A Strength & Balance exercise program
- 20 health checks were conducted, leading to tailored medication adjustments and appropriate referrals (e.g., Therapy4U, Social Prescribing).
- 13 patients joined the Strength & Balance class, with an additional 6 friends and family members participating—bringing the total to 19 attendees.
- The 13-week program featured guest speakers from Adult Social Care, ECC Slipper Swap Initiative, and local leisure providers, helping participants access local support services.
Each participant received a Falls Pack containing:
📄 Printouts of strength & balance exercises
📄 Information on falls prevention
📄 Details of local resources and exercise classes
Patient Feedback & Outcomes
Post-project surveys revealed that participants felt more confident in their strength, balance, and social interactions. Beyond physical benefits, patients reported improved mental well-being through meeting new people and engaging in meaningful activities.
🗣 Patient Testimonials:
💬 “I found the service to be friendly, professional, and informative. The staff genuinely cared about the people they were supporting.”
💬 “The exercises were beneficial, and Matthew was an excellent teacher. The program helped me feel stronger, and it was great to connect with others in the community.”
Looking Ahead
These initiatives have demonstrated the value of proactive, community-based healthcare. By focusing on prevention and social prescribing, we have successfully improved patient health outcomes while reducing unnecessary strain on GP practices.
We look forward to expanding these efforts and continuing to support our local community through innovative healthcare solutions.
