How the ACG System Can Help Improve End-of-Life Care

September 28th, 2023
Care Management  |  
Population Health Management & Improvement  |  
Risk Stratification & Population Segmentation
How the ACG System Can Help Improve End-of-Life Care

For many, dying is a difficult topic – even though eventually, it’s something we all experience. And when that time comes, palliative care programs such as hospice can aid this transition. Read more to learn how England-based Dorset ICS (an Integrated Care System) in the National Health Service (NHS) uses the ACG System to accurately and proactively identify individuals who need end-of-life care (or download the full case study here).

Planning Ahead for End-of-Life Care

End-of-life care is defined as any type of care received by someone with a terminal medical condition.1 The quality of care for individuals near the end of life varies greatly around the world. A recent study by the Journal of Pain and Symptom Management ranked the U.S. 43rd out of 81 countries surveyed in terms of quality of care.1 Planning ahead for end-of-life care ensures individuals die with dignity and with control over the type of care they receive.

Typically, individuals enrolled in Medicare can receive hospice with a clinical documentation that death will likely happen within six months. And unfortunately, when that time comes, most individuals in the U.S. die in hospitals or nursing homes without any pre-planning.2

A National Program with Massive Impact

In England, the NHS created a program with a vision of improving end-of-life care across the country. The goals of the program are to ensure that individuals are treated fairly, have access to proper care and competent caregivers, and are able to decide what their own end-of-life care should look like. An enhanced program was created for Dorset ICS in southwest England to provide additional support for these patients.

Dorset created a Supportive and Palliative Care Register to track patients who are near the end of life. When the provider makes the clinical decision that a patient is approaching death, the patient can choose to be included on the register. This allows the patient to have discussions with their provider about end-of-life care, where they would like to receive care and the types of treatments they wish to undergo or avoid.

Predictive Modeling to Anticipate End of Life

Dorset and the NHS wanted to understand how the register was being used. They found that of the approximately 8,500 deaths in Dorset in one year, only 11.9% of those individuals were on the register. Dorset and the NHS knew thousands of individuals were missing out on this important level of supportive care. Dorset then used a predictive model developed by the ACG System to proactively identify patients across the entire patient population who were at a high risk of dying within the next 12 months. Patients were given a score based on details surrounding a documented diagnosis which allowed providers to isolate the population with the highest scores and arrange for additional assessment in order to best support them.

Expected Benefits

The ACG System provided comprehensive data and effective population health management strategies for Dorset ICS. Given the results from the models, it is reasonable to expect a substantial decrease in unexpected ED visits in this end-of-life population, fewer admissions and lower costs for the hospital and insurers. Clear benefits to the program are that individuals approach the end of life on their own terms and with their final wishes intact.

End-of-life care is an important step as we age. The Johns Hopkins ACG System helped Dorset ICS identify patients who would benefit from this program that otherwise would not have been included. Not only did the ACG System improve costs and reduce admissions, but it also allowed for an extraordinary impact on quality of life for those individuals. To read the full case study, click here.

To learn more about the ACG System and how it’s driving benefits in end-of-life care, please visit hopkinsacg.org, or email acginfo@jh.edu. If you are an ACG customer, please contact your account manager.



1 https://hospicenews.com/2022/01/26/study-u-s-ranks-43rd-in-end-of-life-care-quality/

2 https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care



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