John Hopkins: Segmentation (Patient Need Groups)

You may notice a test result in your NHS App that refers to “Johns Hopkins Adjusted Clinical Groups”. This relates to a care planning tool we use to help better understand and support individual patient needs. The system places patients into categories known as Patient Need Groups (PNGs).

The tool, called the ACG® System, was developed by Johns Hopkins University and is widely used internationally to support healthcare planning and improve patient care. By using this system, we can gain a clearer picture of our patients’ overall health and wellbeing needs, helping us provide more personalised, proactive, and timely support.

What is segmentation (Patient Need Groups)?

Segmentation is a way of grouping patients according to the complexity and level of their healthcare needs.

Rather than focusing only on a specific condition, such as diabetes or heart disease, segmentation considers a wider range of health factors to build a more complete understanding of each person’s overall needs and the type of care and support they may benefit from.

How Do Patient Need Groups (PNGs) Work?

The ACG® System uses an established model developed through research by Johns Hopkins University, which places patients into one of 11 groups based on their healthcare needs.

These groups consider a range of factors, including:

The number of health conditions a person has
The seriousness and complexity of those conditions
The type and level of care or support they may require

This approach helps our team identify patients who may benefit from closer monitoring, additional support, or preventative and lifestyle-focused 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.

Who May Be Involved in Supporting You

Depending on your Patient Need Group, you may receive support from different members of our Multidisciplinary Team (MDT). Not every patient will require input from all services; however, the following support is available where appropriate:

Pharmacists – Medication reviews, optimisation, and safety
Geriatricians – Specialist care for older adults and people living with frailty
Social Prescribers – Support with wellbeing, lifestyle, and non-clinical needs
Physiotherapists – Mobility support, falls prevention, strength, and balance
Occupational Therapists – Functional assessments, equipment provision, and home environment support
Speech and Language Therapists (SALT) – Support with swallowing difficulties and communication needs
Dietitians – Nutritional support, including frailty and unintentional weight loss management
Social Workers – Social care support and safeguarding
Housing Services – Assistance with housing needs and home adaptations
Heart Failure Nurses – Specialist monitoring, advice, and ongoing support
Diabetes Specialist Services – Diabetes management and education
Respiratory Teams – Support for respiratory and lung conditions
Learning Disability Services – Tailored healthcare support for people with learning disabilities
Mental Health Practitioners – Emotional wellbeing and mental health support
Dementia Specialists – Memory assessment and support for people living with dementia

We work to ensure that the most appropriate members of the MDT are involved in your care according to your individual needs. Where services are not currently available, this is taken into account in ongoing service planning and future 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