John Hopkins: Segmentation (Patient Need Groups)

You may notice a test result appear in your NHS app referring to Johns Hopkins adjusted clinical groups. In order to help us tailor care according to individual patient need, we now have access to a tool that segments or categorises our patient population into Patient Need Groups (PNGs).

This system of segmentation, called the ACG® System, was developed by Johns Hopkins University, which is renowned for its contributions to advancing medical practices and healthcare systems globally. Segmentation helps us as a practice understand the individual needs of our patients based on their health and wellbeing to support personalised care and ensures you get the right support in a timely way.

What is segmentation (Patient Need Groups)?

Patient Need Groups categorise patients into different groups based on the complexity and intensity of their healthcare needs rather than just their medical conditions. Instead of focusing solely on a diagnosis (like diabetes or heart disease) it takes in to account a broader range of health characteristics about a patient.

How do PNGs work?

They are formed using a well-tested set of 11 segments/groups based on research by John Hopkins University.

Factors used for grouping include the number of conditions a person has and how severe they are. This helps in deciding what level of support a person may need.

For example:

• Red PNG 10 & 11 = Complex Care Needs: Patients with multiple chronic conditions, requiring regular monitoring and a coordinated care approach.
• Amber PNG 5-9 = Stable Chronic Conditions: Patients with chronic conditions that are well-managed and require occasional support to maintain their stability.
• Green PNG 1-4 = Healthy: Patients without significant health issues who could benefit from preventive care.

As patient needs change over time, their categorisation changes with them.

PNG offers an at-a-glance indication of a patient’s broader needs, at a point in time.

How is segmentation (PNGs) done?

1. Data Collection: The process begins with collecting data from various sources. Segmentation is part of the same platform as the TVS Care Record and uses the same data.
2. Identifying Segments: The TVS Care Record platform runs the John Hopkins algorithm. This groups people into the 11 segments. It uses information like what conditions a person has and how often they see a doctor.
3. Analysis Tools: Health and care staff use tools to identify groups with different needs. The health team uses the 11 segments plus other factors and expert input to determine which these groups are. In BOB ICB, the team uses the tools provided by the TVS Care Record platform.
4. Intervention: We can use this analysis in one of three ways. The first is to provide active treatment to the selected group (e.g. inviting them for a blood pressure check-up). The second is to change how we work for that group (e.g. longer appointments for more complex patients). The third is to change the services we provide (e.g. increasing the number of specialist nurses in a certain area).

What are the benefits of segmentation (PNGs)?

1. Personalised Care. By understanding the needs of each group better, we can personalise care to those people. This means patients receive the specific type of care they need, whether it’s more frequent monitoring, specialised treatment, or preventive care.
2. Resource Allocation. By using the best treatment for each group, it helps us make best use of our resources and staff. It also means we can direct people to the right place first time.
3. Improved Coordination. PNGs help healthcare teams coordinate more effectively. If a patient has complex needs, the care team can work together to ensure all aspects of their health are addressed, from medication management to lifestyle support.
4. Improved Health Outcomes. We can better identify those who need early interventions or tailored care plans. This leads to improved health outcomes, particularly for patients with chronic conditions.
5. Preventative Care. We can identify people who may need treatment before issues occur. By preventing complications, we can keep people healthier for longer.
6. Enhanced Communication. PNGs facilitate better communication between patients and healthcare providers. By understanding which group a patient falls into, together they can have clearer discussions about what to expect from the care they receive and what actions they can take to manage their health.