The Integrated Motivational Proactive Anticipatory Care Team (IMPACT) is supporting the development of sustainable general practice by utilising population health intelligence to tackle neighbourhood health inequalities through proactive personalised care and support planning.
A team of care coordinators employ person-centred and motivational approaches to support patient-led identification of biopsychosocial needs, before collaboratively formulating a personalised care and support plan to address patients' current challenges.
Utilising their enhanced knowledge of system-wide services, IMPACT care coordinators navigate patients to the most appropriate intervention(s) which will support more efficacious self-management.
Currently, IMPACT makes proactive contact with patients who have a specific unmanaged long-term condition, dependent on the neighbourhood. Type II diabetes patients in central and west Norwich, asthma patients in north Norwich and COPD patients in east Norwich.
Since June 2021, over 500 personalised care and support plans have been formulated, resulting in over 350 referrals to system-wide services. Only 9 percent of these referrals were for input by a general practitioner.
Three-month reviews are currently underway and
following the completion of these (anticipated end of December 2021), the team
will conduct a thorough evaluation of outcomes which will direct future work.