John Hopkins – Segmentation (Patient Need Groups – PNGs)

You may notice a test result that appears in your NHS app referring to John Hopkins Score (Patient Need Groups).

What is segmentation (Patient Need Groups)?

Segmentation (PNGs) is a simple way of categorising patients based on their specific health needs. It helps us as a practice understand the individual needs of our patients based on their health and wellbeing needs. This will enable personalised care and ensure patients get  the relevant support.

John Hopkins Adjusted Clinical Groups

Segmentation is part of the TVS Care Record platform – learn more about the TVS Care Record here.

We use segmentation to group people based on shared characteristics, needs, or behaviours. This allows us to tailor care delivery and policies to better meet the specific needs of each group.

When we do this for all groups we get healthier people and a healthier population.

What are the John Hopkins Patient Need Groups (PNGs)?

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

The categories break down into:

• Low need (PNG 1-4) – people without significant health issues who need less intervention. Preventative care may stop them becoming unwell.
• Moderate need (PNG 5-9) – people who have a condition that is well managed. They may need occasional support to remain stable.
• High need (PNG 10-11) – people who have several conditions. They may need regular monitoring or a more coordinated approach.

You may have seen this score in your NHS App as “John Hopkins adjusted clinical groups system score”.

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)?

• 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.

• 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.
• 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.
• 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.
• Preventative Care. We can identify people who may need treatment before issues occur. By preventing complications, we can keep people healthier for longer.
• 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.