Changing the conversation about health

Prevention Plan Population Health Management

CoM Tags:

ehealth, college of medicine

The Prevention Plan™ is a ground breaking programme that enables individuals to determine their top health risks and receive a customised plan to lower those risks and become healthier.

Health care costs are rising fast and effective solutions will not come forth from within the existing ‘treatment’ focused provider systems. For a long time it has been obvious to every individual and organisation paying for escalating medical bills, that the current way of doing things – focusing on sickness instead of maintaining good health – just isn’t working.

NHS Efforts include:

  • Home-bound COPD patients get access to a comprehensive online self-management system (risks, care plan, prevention schedule, health record, behaviour change, messaging, coaching). Clinical staff get access to a monitoring, workflow and communication backend.
  • Primary Care (Dr Ian Greaves / Staffordshire, multiple LTC patients)
  • Preventive Population Health Management (DCHS – Derbyshire Community Health Services NHS Trust) Further workforce efforts: ca. 600 population health participants and ca. 1700 population claims case management.


Year established
Number of staff
4 FT equivalent
Number of users
1,000 + on our Prevention plan
Is there a charge to users?
Free at the point of delivery.  Staff service subsidised by the Trust.
What makes your project sustainable?
This work is still at a pilot stage, and we will be exploring this near the end of our first batch of projects.
User demographics
Addenbrookes: High-risk COPD patients, aged 50+ and up to 83 years old, 2+ of project users admissions in last year and poor respiratory function.Staffordshire: Mix of long-term condition patients (in 50s to 70s). Derby: NHS workforce demographics, focus on lower-earning / higher absence.
Addenbrookes: Home-bound patients struggle to attend hospital-based self-care trainings, care co-production enhances self-management while keeping the patient connected to the clinician. The emphasis (unlike in telecare) is on education, self-care & behaviour change. The platforms functionality is uniquely comprehensive (see 2a) and e.g. addresses mental health issues alongside the COPD issues, taking a comprehensive patient-centric view.Staffordshire: self-care tool for patients for general health improvementDerby: NHS workforce health improvement
Patient-centred, whole-person, preventative approach
The patient and a preventive / anticipatory approach is at the core of the design: personal top risks, personal prevention schedule, risks link to behaviour change programmes, the whole platform enables the patient to have access to almost all they need to manage their health. The diagram below illustrates the approach:
Evidence-informed practice/audit and evaluation
The diagram below shows impact of a 2-year intervention combining: Assessment (pre and post) – online self-assessment – health screening Intervention – self-management platform with all elements described in 2a – proactive personal coaching (electronic & telephonic) – incentives
Multi-disciplinary collaboration, communication and professional practice
At Addenbrooke’s nurses and specialists collaborate on the care delivery – the system design would allow a full care team to collaborate through the back end.
Quotes from service users
‘I wish I had had this when I was last home-bound in the winter.’‘Let’s face it, I don’t usually have such personal support and access.’‘It’s transformed the way I manage my health.’
Contact details
Stefan Wisbauer
First Floor
3 Palliser Road

W14 9EB