Region Värmland Optimises Care for Frail Patients Using the Johns Hopkins ACG® System in collaboration with LOGEX

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At a glance

Region Värmland in Sweden has 283,000 residents, with an average of 2,100 daily visits to regional physicians. To better support patients with complex needs, Region Värmland implemented a data-driven approach in partnership with LOGEX, integrating the Johns Hopkins ACG System into its data reporting solution (SELMA). This integration enables the identification and proactive management of patients with multi-morbidity, frailty and high resource utilisation. By combining ACG analytics with LOGEX’s cost measurement system, the team can pinpoint high-risk patients and optimise primary care delivery. 

The result

The result: fewer avoidable emergency room visits and hospitalisations, improved continuity of care — including the deployment of local mobile health care teams, and more efficient resource allocation. The solution has been piloted with more than 1,000 patients across 26 health centers, with plans to expand further to include more private providers. 

Benefits

Targeted care for frail patients

ACG-based risk stratification and segmentation helped care teams to prioritise the most vulnerable, ensuring earlier interventions and tailored support

Reduced system-wide costs

Coordinated care through mobile teams reduced hospital admissions and ambulance calls, increasing overall system efficiency 

Data-driven decision making

By combining patient data, LOGEX’s cost measurement solution, and ACG System analytics, teams derived comprehensive analytic insights, leading to informed decisions that benefited patients and providers alike 

"We are convinced that the overall picture we get thanks to LOGEX can be used to identify, introduce and follow up various improvement initiatives in health care."

Region Värmland

Challenges

Region Värmland identified that some of its most frail patients often experienced multiple health care encounters, leading to complex and fragmented care journeys for patients and inefficient resource use. The goal was clear: improve care coordination and care delivery in primary care settings for patients with the most complex needs. 

Solutions

In 2022, Region Värmland partnered with LOGEX to integrate the ACG System into its patient selection tool, which has enabled advanced risk stratification and more precise identification of high-need patients. Using the ACG System’s Patient Needs Groups (PNGs), the team segmented the population to identify patients with multi-morbidity, high complexity and frailty.

Additional ACG System risk stratification tools helped identify:

• The highest utilisers of health care resources

• Patients likely to be in the top 5% of high cost cases within 12 months

• Other demographic, clinical, geo-social and utilisation risk factors

These insights informed the redesign of care pathways to meet patients’ needs and improved the patient experience. Mobile care teams were deployed to reach patients directly, reducing hospital visits and ambulance calls while delivering targeted, cost-effective interventions across care settings. 

"With LOGEX and ACG System’s help, we can always find new ways forward to optimise the care pathways for our patients."

Hans Carlsson

Operations Analyst at Region Värmland

Key metrics

Reduction in avoidable hospitalisations & ambulance usage (as a result of redirection of care)

Optimised resource allocation across care settings

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