Brookside Group Practice in Berkshire has significantly improved patient care and operational efficiency by creating an advanced digital triage solution in partnership with Connected Care (a Frimley ICS and Partners system transformation enterprise) - with support from Graphnet. The system is revolutionising care prioritisation by offering RAG (Red, Amber, Green) ratings for patients presenting conditions alongside their background health, enabling the right care professional with the right skill set to see the right patient at the right time.

The team at Brookside worked with their digital triage platform provider and the Connected Care team to incorporate the Johns Hopkins ACG ® System patient segmentation risk scores derived from the Connected Care population health management (PHM) platform, into their triage software.

This transformative approach has reduced waiting times and call durations from 18 minutes in January 2023 to 4 minutes by December 2023, with over 75% of patients now accessing care online.

The results highlight how exceptional outcomes can be achieved through data-driven digitally enabled transformation initiatives.

The  Connected Care population health platform is powered by data from the regional Thames Valley and Surrey shared care record, a Graphnet solution, and is  in active use across Frimley Health and Care and Buckinghamshire, Oxfordshire, and Berkshire West (BOB) Integrated Care Systems (ICSs).  

The Challenge

During the COVID-19 pandemic, Brookside Surgery faced challenges in ensuring continuity of care for patients. After the pandemic, they wanted to introduce changes that would reduce administrative burdens on team members whilst improving the quality and timeliness of access to healthcare for their patients.

The Solution

The team at Brookside Surgery wanted to introduce ways that would improve triage efficiency, enhance care equity, reduce waiting times for patients and optimise their Patient Health Teams model.

The incorporation of the ACG System into the Connected Care platform has enabled sophisticated cohorting of patients into one of eleven clinically relevant, mutually exclusive and hierarchical Patient Need Groups (PNGs) or ‘segments’. The tool categorises people based on their overall level of complexity – taking into account characteristics like their disease profiles (their morbidity), the medications they are on, and the care encounters they needed (the resources they use).

Using the Connected Care population health platform means patients are assigned to a PNG – and this at-a-glance signal indicating a patient’s background health is enabling timely and appropriate care as patients get assigned to the right clinician or team.

This Patient Health Teams (PHT) model – a multidisciplinary approach - ensures continuity in care and optimal use of healthcare resources.  

By presenting a patient’s current segmentation alongside their presenting problem, the solution helps non-clinical triage teams to flag their more complex patients and ensure they receive timely care. This approach combines historical patient data with current issues to assess risk and prioritise care effectively.

Results and Benefits

The implementation of the solution has demonstrated measurable improvements:

• Enhanced patient access: Reduced waiting times and call durations (from 18 minutes in January 2023 to 4 minutes by December 2023), with over 75% of patients now accessing care online.
• Improved continuity of care: Patients benefit from dedicated care teams familiar with their medical histories.
• Operational efficiency: The triage system has streamlined workflows, reducing clinician administrative burdens and optimising appointment scheduling.
• Risk stratification: Comprehensive risk assessment allows prioritisation of care for patients with the greatest needs, ensuring equity and timely intervention.
• Empowered Workforce: Reception and triage teams have more confidence handling patient requests more efficiently, enabling clinicians to focus on care delivery.
• Clinicians have more comprehensive clinical information, enabling them to make better-informed decisions.

Brookside Surgery’s innovative approach has set a benchmark for primary care transformation and won recognition, including a prestigious HSJ award in the ‘Improving Primary Care Through Digital’ category.

Dr Amit Sharma, GP Partner and Strategy Lead at Brookside Surgery, says:

Segmentation and digital triage are tools that can transform care delivery, whatever the context. 

Natasha Poller, digital transformation manager, Brookside Surgery Group says: 

Segmentation has made a huge difference to how we do our triage, and that's made a massive difference in terms of our delivering continuity of care for our most vulnerable patients and an unexpected secondary benefit has been that we are catching new diagnoses much earlier.

Dr Alison Malcom says:

This model provides everyone with what they need most from general practice: continuity for those with greater health needs and convenience for those who are generally healthy with busy lives.

Brookside Surgery’s success demonstrates the potential for scaling this model across BOB ICS and beyond. Discussions are underway to extend the use of segmentation into secondary care and regional services such as emergency departments and SCAS 111.

The Connected Care platform, combined with the Johns Hopkins ACG System, exemplifies how shared care records can contribute to  advanced population health insights that will revolutionise primary care. This model enhances patient outcomes, boosts efficiency, and sets a standard for healthcare innovation across the NHS.