We were doing this for older people when I retired 12 years ago. The objective is to identify people who are "frequent fliers" or at risk of becoming frequent users and putting things in place to stop that happening and/or to get them to the right place asap so as to save them getting stuck elsewhere which is not good for them and wastes resource.....simple things like giving people which chronic illness "just in case medication", giving people who need them direct access to specialist services without needing to go through any kind of referral or triage process, making sure that the proper support is available to them and so on. We were doing this on a case by case basis as we found them which took up our time and wasn't that efficient.