This article explains how Continuity of Care (RAG) is presented and used within Ardens Manager, including how the Red/Amber/Green groupings are derived and how to access and filter the cohorts.
Important: This is Ardens criteria for care continuity purposes only. It is not a clinical risk stratification model and should not be used to make direct clinical decisions.
What is Continuity of Care (RAG)?
Continuity of Care (RAG) is an Ardens-defined grouping used to support care continuity and workload planning by segmenting patients into:
Red (highest care continuity need)
Amber (moderate care continuity need)
Green (lower care continuity need)
The purpose is to help teams understand which cohorts may benefit from more proactive, coordinated, or consistent care, based on coded indicators in the clinical record.
Continuity of Care (RAG) is derived from coded activity and report membership rules, with an additional mechanism that allows practices to override a patient’s grouping where appropriate.
A patient will appear as Red or Amber if either:
They meet the defined report-based criteria, or
The relevant coded risk group has been added directly to their clinical record by the practice
This allows local clinical teams to apply professional judgement where a patient’s continuity-of-care needs are not fully captured by automated criteria.
Red criteria
A patient is assigned Red where they meet any of the following (risk criteria):
In report Frailty – Severe
In report EoL – All
In report Multimorbidity | 5 or more LTCs
Patients may also appear as Red if the following code has been added to their record:
Chronic long term disease management required: complex needs (416357003)
Amber criteria
A patient is assigned Amber where they meet any of the following (risk criteria):
In report Frailty – Moderate
In report Diagnosis – New cancer diagnosis in last 1y – All
Meets both of the following:
In report Multimorbidity | 2 or more LTCs
Not in report Multimorbidity | 5 or more LTCs
Patients may also appear as Amber if the following code has been added to their record:
Chronic long term disease management required (416239002)
Green criteria
Green includes anyone who does not fall into Amber or Red based on the criteria above.
How can Continuity of Care (RAG) be used?
Common care continuity use cases include:
Prioritising patients for more consistent named clinician or team-based follow-up
Planning proactive reviews (for example, for frailty, multimorbidity, or end-of-life support)
Understanding the distribution of continuity-of-care need across practices, PCNs, or ICBs
This measure is intended for service planning and care coordination rather than clinical risk prediction.
How to access Continuity of Care (RAG) in Ardens Manager
Within Ardens Manager, Continuity of Care (RAG) is presented in the Risk section of relevant registers as:
A population chart showing counts by Red/Amber/Green
A filter option to view the corresponding cohorts
Step-by-step instructions
Open any relevant report by selecting 'View' on a dashboard
Go to the Risk tab
In the report view, select the Risk tab
Locate the Continuity of Care – RAG chart
Filter to a cohort (optional)
Select Filter
Expand Risk
Choose Continuity of Care – RAG
Select Red, Amber, or Green as required
Select Apply
Data quality and review reports
Ardens Manager provides a set of data quality and review case finder reports to help ensure patients are recorded in the most appropriate Continuity of Care (RAG) category.
These reports are available under: Services → Population → Risk Stratification → Case Finders
Examples include:
Reviewing patients where a continuity of care need may be missing or outdated
Identifying patients recorded as Red or Amber with lower-than-expected appointment activity
Identifying patients recorded as Green or Amber with higher appointment activity suggesting review
Highlighting patients where the last recorded risk group is over 12 or 24 months old
Identifying patients with housebound or care home status recorded since the last risk group
These case finders support regular review and validation of continuity-of-care coding and help practices apply overrides consistently and safely.