The Johns Hopkins approach to segmentation revolves around considering the entire person, recognising that health needs vary and evolve throughout their lifetime. This approach aligns with the fundamental principle of the ACG System: multimorbidity, or the clustering of diseases, serves as a more accurate predictor of resource utilisation than the presence of a single disease or healthcare event.

All diagnoses documented in the GP record or from secondary care, along with prescribed medications in primary care, contribute to the PNG assignment process. However, activities like community nursing visits or treatment by mental health providers (including hospital admissions and outpatient visits) do not directly impact PNG assignment. If a diagnosis arises during such activities and is electronically recorded, it will be taken into account. Currently, social needs are not part of the PNG assignment process. The Johns Hopkins team is actively assessing the quality of social needs data recorded in the NHS electronic health care record.

Regarding most diagnoses and conditions, the ACG System reviews data from the past 12 months. However, for long-term conditions that may have been documented more than a year ago, the system extends its retrospective analysis to at least 5 years. Additionally, there is ongoing consideration to apply this principle to certain diagnoses related to frailty (such as mobility issues). Even if these events occurred more than a year ago, they continue to serve as valuable indicators of frailty.

Patient Needs Groups (PNGs) are occasionally referred to as a ‘complexity score’. Individuals in higher PNGs exhibit greater multimorbidity, resulting in more intricate care requirements. These needs often span physical, mental health, and social aspects. Notably, there exists a robust association between:

• Greater Resource Utilisation
• Increased Hospital Admissions
• Polypharmacy
• Elevated Risk—with the transition from lower PNGs to higher PNGs

Yes. Individuals will naturally transition between or in and out of the two pregnancy patient groups (PNGs), but a small subset of patients may shift from one segment to another during different time periods. The ACG System takes into account all diagnoses, including both acute and chronic conditions. Consequently, it is possible for someone experiencing a series of acute issues (such as hip replacement, acute cholecystitis, or injuries) to initially be assigned to a higher PNG, and as these acute problems resolve, their assignment may shift to a lower PNG.

Individuals assigned to PNGs 10 and 11 exhibit comparable characteristics, complexity levels, and health needs. However, the key distinction lies in PNG 11, where individuals are aged 65 or older and present two or more conditions associated with frailty, as defined within the ACG System. These conditions encompass issues related to mobility, cognitive ability, continence, vision impairment, or weight loss.

When setting up protocols in EMIS, a patients PNG/RAG status becomes visible to all practice users in their QOF box.

Currently, practices will need to update their lists monthly. After initial set up, practices must access their delegated folder each month for an updated list and action the refresh. Refreshes only involve those patients with a status change, and new patients. This is typically under 1% of the list and takes approximately 15min. Practices must diarise this action. Development work with EMIS to automate the process is underway. We hope to make this available for EMIS users in the near future.

When you receive the patient lists there may be an additional file for ‘unsegmented’ patients. There are potentially three reasons for this:

• New patients: If it is a new patient added to the practice list, it is likely that at the time of running the lists for segmentation, the patient information wasn’t complete. This will resolve itself when the lists get refreshed next month.
• Incomplete information in the patient record: Complete coding is important to ensure correct assignment of PNG codes. Limited information will likely lead to either a lower score for patients or possibly end up in the ‘unsegmented list’.
• Patient Opt-Outs: There are two types of patient opt outs; ‘full patient opt-outs’ and ‘secondary uses opt-outs’. If a patient has fully opted-out they will not have any associated segmentation codes assigned to them and will be part of this list. However Secondary uses opt outs are included in this list as this use of the data is related to direct patient care. NB: if you've not updated your list for a while, this might be contributing to a larger proportion of opt outs. This has been reviewed internally and by our supplier GraphNet, and as this affects direct patient care, opt outs are now included on your refresh lists. They will therefore all have an assigned segmentation code.

Numbers not matching may be due to patients having opted out of sharing their data for the purpose of secondary use.

Clinical judgement should always take priority. The first action to take is to check that your patients coding is current and complete. If you have checked the above and would like further investigation, please contact our team.

A key principle to the design of this segmentation approach is to maintain consistency across the ICS, a common language/standardised tool for use across the system, irrespective of the setting it is being used in. It is therefore against recommendation to amend the protocols locally. As a mitigation, we advise practices to make provisions for any local exceptions in their local processes and SOPs, and ensure these are communicated within the practice

Yes. PNG/RAG are batch coded to patient records. This code will remain on their record when they move, but only display in EMIS if the new practice has the segmentation protocols. New patients joining a segmentation practice without a PNG/RAG will get assigned one on the monthly list refresh process.

As PNG assignment relies on codes being added to a patients record, depending on the access a patient has, they may be able to see limited information about their segmentation status. We are actively exploring a solution to hide the code - make it available for internal practice use only

If your practice has turned on access to patient records, the patient will be able to view their record in the patient app. This is because, currently, the associated SNOMED codes have values assigned that are being recorded as a test result by EMIS.

The calculations that generate a PNG score are complex, the intellectual property of Johns Hopkins University and cannot be manually overwritten. If you have a query about a particular patient, we can provide a brief summary of some of the conditions and medications contributing to a score. Contact your deployment lead or analyst for more information.