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)

Supplementary Information (September 2018)