Evaluate: Impact on Individuals, Communities and Local System
EVALUATE: impact on individuals, communities and local systems
The initial suite of outcome metrics (see table) will provide a clear picture of the current achievement level and degree of variation at organisation level across the North East and North Cumbria.
The suite has been developed in collaboration with the North East Quality Observatory Service (NEQOS, https://www.neqos.nhs.uk/) and the North of England Commissioning Support Unit, Business Intelligence (NECS, https://www.necsu.nhs.uk/).
Presently, the metrics are based on a review of regional and national work and will be refined over time
Ageing Well – Frailty Outcome Framework
| No. | Part of system | Metric | Organisation level |
|---|---|---|---|
| 1 | Primary Care | Number of patients who have had a frailty assessment | GP practice / CCG |
| 2 | Primary Care | Number of patients who are identified as living with frailty, and the degree of their condition (mild, moderate, severe) | GP practice / CCG |
| 3 | Primary Care | Number of patients with severe frailty, recorded as having had a fall in the preceding 12 months | GP practice / CCG |
| 4 | Primary Care | Proportion of people with severe frailty who have their written care plan reviewed with them regularly (minimum requirement annually) | GP practice / CCG |
| 5 | Primary Care | Number of patients aged 65+ years with 10 or more unique medications | GP practice / CCG |
| 6 | Care in the community | The proportion of people who use services who have control over their daily life | Local authority |
| 7 | Care in the community | The proportion of people who use services who reported that they had as much social contact as they would like | Local authority |
| 8 | Mental Health | The rate of those aged 65+ with a recorded diagnosis of dementia compared to those estimated to have dementia based on the CFAS II model | CCG |
| 9 | Emergency care | A&E attendance rates for patients aged 65+ years | GP practice / CCG |
| 10 | Emergency care | Unplanned admission rates for patients aged 65+ years | GP practice / CCG |
| 11 | Emergency care | Emergency readmissions within 30 days of discharge from hospital for those aged 65+ years | GP practice / CCG |
| 12 | In hospital delays | Stranded patient: LOS 7+ and 21+ days | GP practice / CCG |
| 13 | Social care – discharge | The proportion of older people (aged 65+years) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services | Local authority |
| 14 | Social care – discharge | Long-term support needs of older adults (aged 65+ years) met by admission to residential and nursing care homes, per 100,000 population | Local authority |
| 15 | Mortality | Percentage of deaths in usual place of residence for those aged 65+ years | CCG |
| 16 | Primary care | Flu immunisation rate in people aged 65+ years | CCG |
| 17 | Care in the community | Reduced loneliness | to be determined |
| 18 | Care in the community | Number of people referred into social prescribing schemes and number of people rejecting a referral (patients aged 65+ years) | CCG |
| 19 | Primary Care | Patients on the MH registers (dementia, depression and anxiety) and with frailty | GP practice / CCG |
| 20 | Care in the community | Carer reported quality of life | Local authority |
| 21 | Emergency care | Conversion rates (A&E attendance to emergency admission) for patients aged 65+ years | GP practice / CCG |
| 22 | Emergency care | Hospital activity in the last year of life for those aged 65+ years | GP practice / CCG |
| 23 | Secondary care | Composite quality bundle: A&E 4 hr compliance, Falls, pressure ulcers, improved patient experience, discharge to normal place of care. | Hospital trust |
For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures go to the ‘Frailty Toolkit pages 93-95..
Regional Frailty Outcomes Report (September 2018)
