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John Hopkins: Segmentation (Patient Need Groups)

You may notice a test result in your NHS App referring to “Johns Hopkins Adjusted Clinical Groups”. This relates to a tool we use to help tailor care more effectively to individual patient needs. The system groups patients into what are called Patient Need Groups (PNGs).

The segmentation tool, known as the ACG® System, was developed by Johns Hopkins University and is widely recognised for its contribution to improving global healthcare. By using this system, we can better understand the overall health and wellbeing needs of our patients, allowing us to offer more personalised and timely support.

What is segmentation (Patient Need Groups)?

Segmentation is a method of categorising patients into different groups based on the complexity and intensity of their healthcare needs.

Rather than focusing solely on a diagnosis (such as diabetes or heart disease), segmentation looks at a broader range of health characteristics, building a more complete picture of the type of care each person may require.

How Do Patient Need Groups (PNGs) Work?

The ACG® System uses a well‑established set of 11 different groups created through research by Johns Hopkins University.

These groups take into account factors such as:

  • The number of health conditions a person has
  • How severe those conditions are
  • The type and level of support the person may need

This helps our team determine who may need more active monitoring and who may benefit from preventative or lifestyle‑based care.

Examples of PNG Groups

  • Red PNG 10–11 — Complex Care Needs
    • Patients with multiple, often serious long‑term conditions who require frequent monitoring and coordinated support.
  • Amber PNG 5–9 — Stable Chronic Conditions
    • Patients with long‑term conditions that are generally well‑managed but require occasional support to maintain stability.
  • Green PNG 1–4 — Healthy / Lower Needs
    • Patients without significant health issues who may benefit from preventative advice and routine care.

As your health needs change over time, your PNG classification may change too.

This provides clinicians with a quick, at‑a‑glance snapshot of your broader care needs at any given moment.

Low need

  1. 1Non-user
  2. 2Low need Child
  3. 3Low need Adult
  4. 4Low Complexity Morbidity

Medium need

  1. 5Medium Complexity Morbidity
  2. 6Pregnancy Low Complexity
  3. 7Pregnancy High Complexity
  4. 8Dominant Psychiatric Condition
  5. 9Dominant Major Chronic Condition

High need

  1. 10Multi-Morbidity High Complexity
  2. 11Frailty

Who May Be Involved in Supporting You

Depending on your Patient Need Group, different professionals from our Multidisciplinary Team (MDT) may be involved in your care. Not every patient will need every type of support, but the following services are available where appropriate:

  • Pharmacists – Medication reviews, optimisation, and safety
  • Geriatricians – Specialist care for older adults or those with frailty
  • Social Prescribers – Support with wellbeing, lifestyle, and non‑clinical needs
  • Physiotherapists – Mobility, falls prevention, strength and balance
  • Occupational Therapists – Functional assessments, equipment, home environment support
  • Speech & Language Therapists (SALT) – Swallowing concerns, communication support
  • Dietitians – Nutrition, frailty, unintentional weight loss
  • Social Workers – Social care support and safeguarding
  • Housing Services – Support with home adaptations or housing needs
  • Heart Failure Nurses – Specialist monitoring and guidance
  • Diabetes Specialist Services – Management and education
  • Respiratory Teams – Support for breathing and lung conditions
  • Learning Disability Services – Tailored healthcare support
  • Mental Health Practitioners – Emotional wellbeing and mental health care
  • Dementia Specialists – Memory assessments and support for those with dementia

We ensure that the right members of the MDT are available according to your needs. Where services are not currently available, this is considered in planning and future service development.

What This Means for You

Using the Johns Hopkins ACG® segmentation tool allows us to:

  • Better understand your health needs
  • Plan your care more effectively
  • Offer more personalised, proactive support
  • Ensure the right professionals are involved at the right time

 

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