Unlocking Effective Population Health Management with the Johns Hopkins ACG® System

At Graphnet, we are committed to empowering health systems with innovative tools that transform patient care. Many of our customers rely on the Johns Hopkins ACG System, a proven set of population health analytics tools, to enhance their population health strategies. The ACG System provides invaluable insights by segmenting populations based on health needs, enabling healthcare providers to deliver tailored interventions that improve patient outcomes and optimise resource allocation.

What is Population Segmentation and Risk Stratification?

Population segmentation is a data-driven method that divides large and diverse populations into smaller, more manageable subgroups based on common characteristics. By understanding these subgroups, healthcare providers can better address the specific needs of each patient. Risk stratification, on the other hand, involves prioritising individuals based on their risk for future health events, such as hospital admissions or disease progression.

Together, segmentation and stratification allow health systems to plan services more effectively, ensuring that resources are allocated where they are most needed. For example, by identifying patients with complex multi-morbidity, providers can then further stratify these individuals to focus interventions on those at the highest risk of adverse outcomes, such as falls or hospital readmissions.

The ACG System and Patient Need Groups (PNGs)

The Johns Hopkins ACG System offers a unique approach to population segmentation through its Patient Need Groups (PNGs). This clinically based framework assigns individuals to one of 11 distinct and hierarchical groups, based on factors such as chronic conditions, age, and overall health complexity. The ACG System tracks patients across these groups as their health needs evolve, helping clinicians provide timely and appropriate care at every stage.

This segmentation model is not merely based on disease states or clinical events but takes a holistic and personalised view of the patient, considering social factors, behaviours, medications, and overall health. For instance, while many tools identify patients by a specific condition (e.g., diabetes), the ACG System views patients in the context of their total health, offering a more comprehensive understanding of their care needs.

Real-World Impact of the ACG System

Healthcare providers using the ACG System have seen significant improvements in care delivery.

• At Brookside Group Practice in Berkshire, integrating the ACG System into the Connected Care shared care record platform led to a 78% reduction in patient call waiting times—from 18 minutes in January 2023 to just 4 minutes by December 2023.
• Over 75% of patients at Brookside now access care online, streamlining workflows and reducing the burden on clinical staff.
• The use of risk-based segmentation with a RAG (Red, Amber, Green) rating system ensures patients are assigned to the right clinician or care team based on their level of complexity and medical need.
• By combining historical patient data with real-time presenting issues, Brookside’s non-clinical triage team can now efficiently identify high-risk patients, ensuring they receive timely interventions before their conditions deteriorate.
• The Frimley Integrated Care System (ICS), which developed the Connected Care platform, has used these insights to redesign its urgent and emergency care model, directing patients toward more appropriate and cost-effective care settings.

Additionally, at Kumar Medical Centre in Slough, the ACG System played a critical role in reducing hospital admissions by 33%. By identifying high-risk patients early in the year, the centre was able to implement proactive interventions, ensuring individuals received the most appropriate care before their conditions worsened.

Brookside Surgery’s approach has been so impactful that it has won an HSJ award in the Improving Primary Care Through Digital category, setting a new standard for healthcare efficiency and patient experience.

Integrating the ACG System with Graphnet’s Population Health Platform

The combination of the ACG System integrated into Graphnet’s Population Health Platform offers a powerful solution for healthcare providers to use real-time data to segment patient populations, identify high-risk individuals, and implement targeted interventions. Whether for preventive care, chronic disease management, or urgent care triage, this powerful combination helps ensure the right care is delivered at the right time.

By embracing the Johns Hopkins ACG System within Graphnet’s platform, healthcare systems can move towards more proactive, data-driven care that improves outcomes, enhances patient satisfaction, and optimises resource usage.

Learn More

To learn more about how the Johns Hopkins ACG System can support your population health strategy, contact marketing@graphnethealth.com.  You can also visit Hopkins ACG for more information.