The Johns Hopkins Stratification Tool 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.
The categories break down into:
- Low need (1 to 4) – people without significant health issues who need less intervention. Preventative care may stop them becoming unwell.
- Moderate need (5 to 9) – people who have a condition that is well managed. They may need occasional support to remain stable.
- High need (10 to 11) – people who have several conditions. They may need regular monitoring or a more coordinated approach.
How is the Stratification process done?
- Data Collection: The process begins with collecting data from various sources.
- Identifying Segments: The EMIS platform runs the Johns Hopkins algorithm. This groups people into the 11 segments. It uses information such as what conditions a person has and how often they see a doctor.
- 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.
- 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 The Stratification Tool
- 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. Stratification tools 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. Stratification tools 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.