Thatcham Medical Practice in Berkshire, part of the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System, wanted to better manage the growing number of appointment requests from its 19,000+ patient population and to optimise patient care and outcomes. Using segmentation risk scores, created from data held in the Thames Valley & Surrey (TVS) Shared Care Record, powered by Graphnet Health, the practice has enhanced patient care, patient management and operational efficiency whilst optimising clinical decision-making.

The practice uses Johns Hopkins ACG® System PNG Segmentation. These scores are dynamic in nature and regularly updated to patient records by the ICS’s population health management tool, Connected Care System Insights. Connected Care is an NHS Digital Transformation Programme run by Frimley ICS and Partners. In partnership, Graphnet and Connected Care generate and embed these scores in practice records helping practices stratify patient populations and view an indicator of an individual’s clinical risk, in their record.

Receptionists now use segmentation data to direct patients to the most appropriately skilled clinician and the tool is helping clinical staff by informing triage, appointment structuring, and clinical decision-making. The adoption of segmentation has led to tangible improvements in patient management and workforce efficiency.

Problem

Thatcham Medical Practice was experiencing increasing patient demand for appointments.  They wanted to make better use of the full skillset of the various new members of the team to help improve access and patient experience.

Caroline Dyer, Practice Manager, Thatcham Medical Practice says:

‘We were noticing that our patients were sometimes inappropriately seen when they didn't need to be, and so it seemed sensible to have a look into the different population management tools to see if we could use segmentation to help that and get the balance correct.’

Solution

The team at the practice started to use the segmentation functionality proactively in order to direct the right care to the right patient, reduce health inequalities and enhance the patient experience.

Heike Veldtman, GP Partner, Thatcham Medical Practice and Connected Care Clinical Lead says:

 ‘John Hopkins very cleverly divides our patient population into 11 segments according to their patient needs and that is defined by how healthy you are, how many long-term conditions you have, your use of medication, hospital admission use of the system - so really a lot of different ways in which information comes in to put you in a segment between 1 and 11.’

These segments were then further grouped into three categories: Red, amber and green (RAG rating)

• Red – Patients with complex, high-risk conditions needing frequent intervention (4% of the population
• Amber – Patients with moderate health conditions requiring ongoing management (24% of the population)
• Green – Healthy individuals with minimal healthcare needs (68% of the population)

Dr Veldtman continues

‘Once our team had segmented the patients at the practice, we found that the rating did not reflect how people sought help. For example, patients in the Green section accounted for some 41% of telephone calls, which translated to 43% of face-to-face consultations, while Red patients, who have higher health needs and are more complex, accounted for just over 10% of the telephone consultations, which translated to less than 10% of face-to-face consultations’.

Heike continues:

‘John Hopkins very cleverly divides our patient population into 11 segments according to their patient needs and that is defined by how healthy you are, how many long-term conditions you have, your use of medication, hospital admission use of the system—so really a lot of different ways in which information comes in to put you in a segment between 1 and 11.’

Positive results for patients: Enhanced Triage and Signposting

Once the segmentation exercise had taken place, team members were given guidance on how to best use the information, with receptionists using segmentation insights to guide patients to the right care pathway.

Jenny Groombridge, receptionist, Thatcham Medical Practice says:

‘As receptionists, we use segmentation to signpost and help our patients. When a patient calls, we use the RAG rating as a soft signal to help signpost the appropriate appointment. It means that when we book the appointment, we have information about their background along with what they are presenting with.

For example, if a patient calls up with a UTI, we can see if they're a ‘Green’ patient, we can signpost them to a pharmacy, who can prescribe for an uncomplicated UTI. This also works the other way, sometimes a patient will call asking for a routine appointment. When we hear their symptoms along with their RAG rating, we can always suggest speaking to somebody sooner if we feel it is necessary.’

Optimised Clinical Decision-Making

Segmentation also informs appointment allocation, medication reviews, and follow-up plans, while having a positive impact on patient consultations.

Caroline Dyer, Practice Manager at Thatcham Medical Practice says: ‘We have two doctors looking at all the ‘on-the-day’ triage appointments and giving the patients a call to work out if they can help them over the phone, if they need to bring them in, if they can help themselves, or if they need to be seen. With the Red, Amber, Green segmentation, it makes it very clear who is actually really sick. They will run down that list and try to speak to the Red patients first to make sure that they're being seen and seen early in the day.

Green patients have experienced a reduction in face-to-face consultations while telephone consultations increased, improving accessibility and efficiency.

Red patients saw a 5% increase in face-to-face consultations, ensuring better management of complex conditions.

Darren Cole, Nurse Practitioner, Thatcham Medical Practice says:  ‘I use this day to day to help inform my clinical decision-making, my triage decisions, follow-up plans for patients, the type of appointment we give and how we interact with the patients. When I have contact with a patient and I open their electronic health record, I will be presented with their segmentation score instantly. I have an idea of whether this patient needs something from us today that we could potentially adjust the way we manage them on that day.

For example, a Green 4 patient—if their problem could be managed remotely, then I would lean towards that. In comparison, a Red patient might need more interaction with us before we make a final decision. The good thing about segmentation is that it’s dynamic.’

Dr Veldtman continues: ‘It allows you to drill down more. So, if you see a young person that is coming up Amber or Red, it should highlight that this is not your average teenager or 20-year-old. What else has been happening in their life? We need to look at their care slightly more.’

Potential reduction in hospital admissions:

Early data suggests a reduction in hospital admissions due to improved patient stratification and targeted interventions. Dr Veldtman says: ‘‘Our Green patients - the number of face-to-face consultations has reduced, but telephone consultations have increased. We are addressing patient needs in a different way - a better way  - sorting them out the first time around.

‘Our patients in the Red category - we have actually increased face-to-face consultations for them by almost 5%. The initial data suggests that it's improving hospital admissions, slightly reducing them. It's early - one year in - but early signals suggest that this is the outcome.’

Prioritisation of high-risk patients helps mitigate complications and prevent unnecessary hospital visits.

Pharmacy Optimisation

Sarah Gray, Clinical Pharmacist, Thatcham:

‘For me and the rest of my team, having the population tool has helped us better stratify the way we're structuring medication reviews. Before, I might have called in the patients on 20 medicines first, then 15, then 10. But actually, thinking about the Red patients who are at higher risk of hospital admission or inappropriate polypharmacy, if we can focus on those first, it will hopefully help reduce hospital admissions.

We'd ask for advice and guidance from secondary care because that patient is more complex. It helps us make good clinical decisions, benefitting both the patient and ourselves as prescribers.

‘In our upcoming PQS work, we have 41 patients in a cohort for structured medication review. Of those, one is Red, 60% are Amber, and then a few are Green. We'll look at the Red patients first, then move on to the Amber, then the Green. Before we had this tool, we might have just done them in alphabetical order.’

Futures and preventative health benefits:

Early detection of conditions like prediabetes and hypertension supports proactive interventions to maintain patient health status. Amber patients at risk of progressing to Red receive focused preventive care to avoid deterioration.

Dr Heike Veldtman, GP Partner, Thatcham Medical Practice says:

‘How we approach our patients, and their needs is different now. I wanted to help support them in feeling that we're getting the right patient choices right for their skill set.  This solution focuses on three key points: access, patient needs and dealing with your workforce. I found the segmentation tool to be an ideal thing that brings all these three together. We are addressing patient needs in a different way—a better way, sorting them out the first time around.’

The implementation of the solution has transformed the way Thatcham Medical Practice manages its patient population. By improving triage, optimising appointment allocation, and enhancing clinical decision-making, the practice has streamlined workflows while delivering better patient outcomes. Although the transformation is still in its early stages, initial results indicate a promising trend towards improved healthcare delivery and resource utilisation.