Avon & Wiltshire Mental Health Partnership NHS Trust Commissioning for Quality and Innovation (CQUIN) Schedule 2015/16

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1 Avon & Wiltshire Mental Health Partnership NHS Trust Commissioning for Quality and Innovation (CQUIN) Schedule 2015/16 4A Nationally Mandated CQUIN IMPROVING PHYSICAL HEALTHCARE TO REDUCE PREMATURE MORTALITY IN PEOPLE WITH SEVERE MENTAL ILLNESS Indicator number Indicator name Indicator weighting 4a Cardio Metabolic Assessment and Treatment for Patients with Psychoses 0.25% 4a and 4b Total 4a = 80% of total funding Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) To demonstrate full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in inpatients with psychoses and community patients in Early Intervention psychosis teams. As set out in National Audit of Schizophrenia. As set out in National Audit of Schizophrenia. National CQUIN scheme. Audit data collected via a national process which will be notified early in 2015 Separate audits for inpatients and EIP, with data expected to be submitted during Quarters 2 and 3 of 2015/16 results to be available in Quarter 4. Provider Audit reporting requirements as set out above. Additional direct reporting to commissioners locally in Quarters 1, 3 and 4. Not applicable Not applicable January March % (inpatients), 80.0% (EIP)

2 Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Quarter 4 audit results demonstrate that, for 90% of patients audited during the period (inpatients) or for 80% of patients audited during the period (community EIP), the provider has undertaken an assessment of each of the following key cardio metabolic parameters, with the results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions (eg smoking cessation programme, lifestyle interventions, medication review, treatment according to NICE guidelines and /or onward referral to another clinician for assessment, diagnosis, and treatment) The parameters are: Smoking status; Lifestyle (including exercise, diet alcohol and drugs); Body Mass Index; Blood pressure; Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate); Blood lipids. Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Are there any rules for partial achievement of the indicator at the final indicator period/date? Provider supplies evidence of systematic feedback on performance to clinical teams. 30 April 2016 Yes see below Yes see below

3 Indicator 4a Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 Quarter 2 Implementation plan covering: Board commitment sign-up identified clinical leadership detailed project plan planning for training for all clinical staff systematic feedback process for individual clinical teams planning for implementation of electronic healthcare records data collection of physical health assessment and measurable outcomes with a view to going live in 16/17 (assessed locally by commissioners) No milestone 31 July % Quarter 3 Clinical staff training plan fully implemented (assessed locally by commissioners) Electronic recording of outcomes fully implemented Quarter 4 Results of national Royal College audit - separate samples for: inpatients community early intervention patients 31 January % 29 April % in all, made up of: 30% 20% (See sliding scales below for payment details.) Evidence of systematic feedback on performance to clinical teams (assessed locally by commissioners) 10%

4 Rules for partial achievement at final indicator period/date The two tables below provide for a sliding scale of payment in relation to the element of the indicator which is payable on the basis of the actual audit results for Quarter 4. Audit of inpatients Final indicator value for the partial achievement Q4 threshold % of CQUIN scheme available for meeting final indicator value 49.9% or less No payment 50.0% to 69.9% 25% payment 70.0% to 79.9% 50% payment 80.0% to 89.9% 75% payment 90.0% or above 100% payment Audit of community EIP patients Final indicator value for the partial achievement Q4 threshold % of CQUIN scheme available for meeting final indicator value 39.9% or less No payment 40.0% to 59.9% 25% payment 60.0% to 69.9% 50% payment 70.0% to 79.9% 75% payment 80.0% or above 100% payment

5 4B Nationally Mandated CQUIN IMPROVING PHYSICAL HEALTHCARE TO REDUCE PREMATURE MORTALITY IN PEOPLE WITH SEVERE MENTAL ILLNESS (SMI) IMPROVEMENT GOAL SPECIFICATION Indicator number Indicator name Indicator weighting 4b Communication with General Practitioners 0.25% 4a and 4b Total 4b = 20% of total weighting Description of indicator 90% of patients should have either an updated CPA ie a care programme approach care plan or a comprehensive discharge summary shared with the GP. A local audit of communications should be completed. Completion of a local audit of communication with patents GPs, demonstrating that, for 90% of patients audited, an up-to-date care plan and/or discharge summary has been shared with the GP, which meets the standards of the Academy of Royal Colleges and includes NHS number, ICD codes for all primary and secondary mental and physical health diagnoses, medications prescribed and monitoring requirements, physical health conditions and ongoing monitoring and treatment needs and Recovery focussed healthy lifestyle plans. Numerator Denominator Rationale for inclusion Data source Frequency of data collection The number of patients in the audit sample for whom the provider has provided to the GP an up-to-date copy of the patient s care plan or a discharge summary which sets out appropriate details of all of the following: NHS number; All primary and secondary mental and physical health diagnosis, including ICD codes; Medications prescribed and monitoring requirements; an Physical health condition and ongoing monitoring and treatment needs; Recovery focussed healthy lifestyle plans. A sample of a minimum of 100 patients who are subject to the CPA and who have been under the care of the provider for at least 100 days at the time of the audit. National CQUIN scheme Local audit One audit in Quarter 2

6 Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Are there any rules for partial achievement of the indicator at the final indicator period/date? Provider Reports required in respect of Quarter 2. NA NA Audit undertaken in Q2, July September % Quarter 2 audit demonstrates that, for 90% of patients audited during the period, the provider has provided to the GP an up-todate copy of the patient s care plan or a comprehensive discharge summary for patients with no CPA initiated. Quarter 2 audit demonstrates that, for 90% of patients audited during the period, the provider has provided to the GP an up-todate copy of the patient s care plan, which sets out appropriate details of all of the following: NHS number; All primary and secondary mental and physical health diagnosis, including ICD codes; Medications prescribed and monitoring requirements; an Physical health condition and ongoing monitoring and treatment needs; Recovery focussed healthy lifestyle plans. 31 October 2015 No Yes see below

7 Rules for partial achievement at final indicator period/date Final indicator value for the partial achievement threshold % of CQUIN scheme available for meeting final indicator value 49.9% or less No payment 50.0% to 69.9% 25% payment 70.0% to 79.9% 50% payment 80.0% to 89.9% 75% payment 90.0% or above 100% payment

8 8b Nationally Mandated CQUIN UEC: IMPROVING DIAGNOSES AND RE ATTENDANCE RATES OF PATIENTS WITH MENTAL HEALTH NEEDS AT A&E IMPROVEMENT GOAL SPECIFICATION Indicator number Indicator name 8b Reduction in A&E MH re-attendances Indicator weighing 0.5% Description of indicator Reduce the rate of mental health re-attendances, of those known to AWP, at A&E in 2015/16 and improve A&E diagnosis recording of MH attendances. The work to support the scheme will include the following: Improved, co-produced (with the patient) relapse prevention care plans for known patients on the CPA (Care Programme Approach), which describe safe community alternatives to A&E. Ensuring A&E staff receive training in mental health awareness, assessment and signposting to liaison mental health teams, including basic biopsychosocial self-harm assessments as described in NICE guidance (NICE selfharm CG16). (Two sessions of training will be offered to all ED departments including Bristol). Access to relevant information through increased AWP access to the Summary Care Record and exploration of local systems to share relevant patient information. Use of NHS number to support data sharing and data interoperability. Increased use of electronic means for sharing transfers of care (such as discharge, care plans) between care settings. Ensuring NHS 111, A&E and Ambulance services have access to care plans relating to Mental Health crisis and other information as required for those individuals identified to AWP as repeat A&E attenders and under AWP care. Measures The scheme will be measured in three ways as set out in more detail in the following sections of this specification and the quarterly milestones: 1. Delivery of training to A&E staff

9 2. Evidenced reduction in A&E re-attendances within 7 days 3. Improved results of clinical audit of care plans Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result The number re-attendances at A&E (for psychosis or self-harm at any A&E) within 7 days following attendances where there has been a referral to AWP as specified in the denominator. Number of referrals to AWP for individuals attending A&E with a diagnosis of psychosis or reasons of self-harm. This indicator has been developed to incentivise better data recording and encourage improved and timely communication and intervention between acute trusts and mental health providers to improve outcomes for those with MH conditions seeking urgent and emergency care. AWP referrals data Monthly AWP will collate and analyse data for referrals received from A&E to inform the setting of the baseline. Audit of sample of care plans. Quarterly To be agreed in July 2015 based on review and analysis of available data on referrals to AWP from A&E To be agreed in July 2015 based on review and analysis of available data on referrals to AWP from A&E. Based on achievement of quarterly improvement measures as set out below. As set out in quarterly milestones. As set out in quarterly milestones. Reports on outcomes and improvement work and lessons learned. Consideration will be given to judging final achievement where it can be evidenced that there are circumstances out of AWPs control that cause detrimental impact to the objectives of the scheme e.g. reductions to social care support May 2016 As set out below. AWP will offer training and aim to arrange sessions in mutual agreement with Emergency Departments (ED). Where this offer of

10 in payment? Are there any rules for partial achievement of the indicator training is not accepted by an ED this will not impact on the achievement of the CQUIN. % of CQUIN scheme available for meeting the % of the quarterly measure: 49.9% or less No payment 50.0% to 69.9% 25% payment 70.0% to 79.9% 50% payment 80.0% to 89.9% 75% payment 90.0% or above 100% payment Exclusions Re-attendances for reasons other than psychosis or self-harm or where lack of social care provision has been identified by the service user.

11 Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milest one weigh ting (% of CQUI N sche me availa ble) Quarter 1 Quarter 2 Quarter 3 Quarter 4 a) Collate and analyse data sets and propose baseline position and confirm and agree, with commissioners, % improvement targets to ensure they are realistic and achievable. b) Plan schedule for delivery of training to A&E staff: 2 sessions per hospital. a) *10% reduction in re-attendances on Trust level baseline. b) Complete audit of care plans to establish baseline compliance of inclusion of comprehensive crisis and contingency arrangements including advice and guidance to A&E, 111 and ambulance services as appropriate. c) Delivery of training to A&E staff to planned schedule. a) *20% reduction in re-attendances on Trust level baseline. b) 20% improvement on baseline of compliance with care plan standards. c) Delivery of training to A&E staff to planned schedule. a) *30% reduction in re-attendance on Trust level baseline. b) 20% improvement on Q3 audit of care plans to a maximum compliance level of 95%. c) Delivery of training to A&E staff to planned schedule. August CQPM October CQPM January CQPM NA 30% 30% May CQPM 40% *As per Q1 a) as this is a new data set the targets are to be reviewed and confirmed to be realistic and achievable via analysis of available data and setting of baseline.

12 BaNES CCG Local CQUIN Indicator number BaNES Local 1 Indicator name Care Cluster 11 review Indicator weighting 1.75% (% of CQUIN scheme available) Description of indicator To improve the quality of care for CPA and non CPA clients on the integrated Recovery team caseload who have needs assigned to Cluster 11. Milestone 1 (End of Q1) To review and assess whether each client has been assigned to Cluster 11 correctly Clarify the interventions and approaches that are effective in maintaining the clients health and wellbeing that are in this cluster to include crisis/contingency/alert plan. Milestone 2 (End of Q2) Using the clustering tool in line with assessment and risk profile that enables a decision to be made on which clients require continued support by the recovery team or primary care mental health team. Utilise service user expertise in process. Present the profile process and its conclusions to Primary and community care colleagues. Negotiate pathway/shared care arrangements (to include medicines management and physical healthcare checks) for those with potential for discharge. Identify training needs (for primary/community and mental health staff) Milestone 3 (Q3-Q4) Identify clients able to be part of new pathway arrangements. Implement process for Cluster 11 clients. Discussion of risk, intervention and coordination needs with Cluster 11 clients. Feedback forms sent to service users who have transitioned out of secondary care Numerator Total number of clients on recovery team caseload in Cluster (Feb 2015) Denominator Total number of clients on recovery team caseload 470 (Feb 2015) Rationale for inclusion Parity of Esteem national agenda. Data source RIO and clustering tool Frequency of data collection Quarterly Organisation responsible for AWP provider data collection Frequency of reporting to Commissioner Quarterly but with monthly verbal updates in the performance meeting

13 Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to Commissioner) End of Q1 N/A Quarterly based on rules Based on rules Review and assess all Cluster 11 clients. Final measure end Q1 Interventions and approaches systematically identified. Final measure - end Q1 Presentation of Q1 data to prescribing pathway members, CCG quality team and community care colleagues. Final measure end Q2. Agreement of pathway responses. Final measure Q2 Final agreement on percentage achievements below - end Q2 Application of clustering tool to 80% (TBA end Q2) of relevant Cluster 11 clients agreed at the end of Q1. Final calculation end Q4. Identify clients able to be part of new pathway arrangements. Measure to be agreed by end Q1 Discussion of risk, intervention and coordination needs with 100% of profiled Cluster 11 clients for whom pathway change is indicated in order to devise personalised pathway of care. Final calculation end Q4 40%of feedback forms received back from clients moved into primary care of those 80% positive experiences of processes to enable smooth transition Final indicator reporting date End of March 2016 Are there rules for any agreed inyear milestones that result in See above payment Are there any rules for partial N/A achievement of the indicator at the final indicator period/date? Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to Commissioner) Quarter 1 Review and assess all Cluster 11 clients, check in appropriate cluster. Interventions and approaches systematically identified. Date milestone to be reported June % Milestone weighting (% of CQUIN scheme available)

14 Quarter 2 Presentation of Q1 data to prescribing pathway members, CCG quality team and community care colleagues Agreement of pathway responses. Application of clustering tool to 80% of relevant Cluster 11 clients agreed at the end of Q1. Quarter 3 Identification of clients able to be part of new pathway arrangements. Measure TBA. Discussion of risk, intervention and coordination needs with 100% of profiled Cluster 11 clients for whom pathway change is indicated in order to devise personalised pathway of care. Quarter 4 Feedback forms received back from clients moved into primary care. 80% positive experiences of transition Sep % Dec % March % 100%

15 Bristol CCG Local CQUIN Local Contract Ref AWP 2015/16 Goal name Bristol CCG Local CQUIN Indicator number Bristol 1 Indicator name Improving the quality of inpatient services and optimising length of stay Indicator weighting (% of 1.75% CQUIN scheme available) Description of indicator Outcome 1 (6.25%): In Quarter 1 & 2 AWP will develop a local protocol for agreeing all admissions to OOA non AWP beds. AWP will ensure the protocol fully engages commissioners in the decision making process to ensure local bed capacity is optimised and improved patient experience. Outcome 2 (6.25%) In Quarter 1 & 2 AWP will undertake a 6 month project to monitor and review failed discharges (defined as readmission within 28 days) across adult acute, later life and PICU Bristol beds. The findings will be presented to commissioners with recommendations. Outcome 3 (12.5%): In Quarter 3 & 4 AWP will reduce the number of OOA placements in non AWP beds by 50% - using Quarter 3 & /15 activity as a baseline. Outcome 4 (25%): AWP will ensure that inpatient services are of the highest quality and focussed on supporting a person s journey towards recovery which will optimise length of stay and minimise unnecessary delays. To support this aim the service will deliver reduced lengths of stay. At the end of Quarters 1 and 2 median length of stay will be 33 days across adult acute and 28 days at the end of Quarters 3 and 4. Outcome 5 (50%): Quality improvements will be based on the 5 areas of the Psychologically Informed Environment framework: 1. Developing a Psychological Framework. The Safer Wards initiative will be implemented on all wards. 8/10 interventions will be addressed on each ward 2 initiatives reported on per quarter. The range of psychological therapies will be reviewed across all wards and developed. 2. Developing physical environment and social spaces. Each ward will undertake a further review of their ward environments and develop a plan as required. 3. Staff training and support. The inpatient services will develop and roll out a core training day for all staff on each ward. A CPD programme will be developed and delivered on all wards. Each ward will identify in Q1 clinical

16 Numerator Denominator Rationale for inclusion intervention leads e.g. CBT, DBT and family work. Develop interventions leads through agreed training plans by end Q4. Ensure weekly reflective practice groups are held on each ward, facilitated by psychological therapies staff. 4. Managing relationships. All service users will have a psychological conversation within 48 hours of admission (excluding Laurel ward). All wards will have a weekly community meeting jointly facilitated by a service user involvement worker and staff (excluding Laurel). 5. Evaluation of outcomes. Through monitoring of the CQUIN. Additional quality improvement measures to support care pathways will include: 1. Ensuring that all acute wards have a dedicated STR (support time recovery) worker; 2. Reviewing FED worker roles to ensure improved interface and working with STR/wards, and agree joint working protocol; and 3. Ensuring that all wards complete actions identified in Triangle of Care self-assessment to optimise work with Carers. N/A N/A This CQUIN will focus on improving the quality of local inpatient services, building on and embedding the ongoing inpatient redesign project. Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) It is Bristol CCGs aspiration that no Bristol resident requiring an adult acute bed is placed out of Bristol. The expectation is that services will support individuals within the CCGs commissioned bed base to reduce the number of OOA placements ensuring patients are treated as close to home as possible. Local provider response to local commissioners Quarterly Bristol mental health services (AWP) Quarterly OOA placements in non AWP beds 2014/15 activity TBC 31 March 2016 Final indicator value As per milestone payments below. (payment threshold) Rules for calculation of As per milestone payments below. payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date March 2016

17 Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? Yes, see below. No. Date/period milestone relates to Quarter 1 Rules for achievement of milestones (including evidence to be supplied to commissioner) Develop a plan with clear milestones for implementation of all aspects of this CQUIN. To be discussed and agreed with commissioners at end of Q1. Date milestone to be reported July 2015 Milestone weighting (% of CQUIN scheme available) N/A Outcome 1 Quarter 1 & 2 Local protocol for agreeing all OOA admissions to non AWP beds agreed and fully operational by the end of Quarter 2 April May June July 6.25% Outcome 2 Quarter 1 & 2 6 month project to monitor and review failed discharges across all wards completed. Findings presented to commissioners with recommendations. April May June July 6.25% Outcome 3 Quarter 3 & 4 50% reduction in OOA placements in non AWP beds -using Quarter 3 & /15 activity as a baseline. January 2016 March % Outcome 4: Quarter 1 & 2 Quarters 3 & 4 Outcome 5: Quarter 1 Produce report of inpatient activity showing median LOS and detailing any delayed discharges with reasons for delay and actions taken to mitigate - Median LoS reported as 33 days. Produce report of inpatient activity showing median LOS and detailing any delayed discharges with reasons for delay and actions taken to mitigate - Median LoS reported as 28 days. Conduct a baseline review of psychological therapies, ward environments, and staff training and support across all wards included in the CQUIN including an action plan for improvements to be delivered in Q2-Q4. July 2015 October 2015 January 2016 March % 6.25% 6.25% 6.25% July %

18 Quarter 1 Review STR roles and provision, FED role, and Triangle of Care baselines. Each ward to identify clinical intervention leads e.g. CBT, DBT and family work. Agreed joint working protocol between FED workers and STR workers/wards. Quarter 1 Begin implementation of the safer wards initiative across all wards, reporting on delivery of 2 initiatives per ward at the end of Q1 Quarter 2 Internal monitoring of progress on all aspects of the plan with report on specific milestones to commissioners at the end of Q2 including report on 2 further safer wards initiatives delivered per ward. Quarter 3 Internal monitoring of progress of all aspects of the plan with report on specific milestones to commissioners at the end of Q3 including report on 2 further safer wards initiatives delivered Quarter 4 per ward. Produce outturn report on all aspects of CQUIN including: Final 2 safer wards initiative delivered in Q4; Evidence that ward environment plans have been delivered; Evidence that inpatient services have delivered the core training day and CPD programme for all staff on each ward; Evidence of clinical intervention leads development through training plans; Evidence that weekly reflective practice groups, facilitated by psychological therapies staff, have been held on each ward; Evidence that all service users have a psychological conversation within 48-hours of admission (excluding Laurel ward); Evidence that all wards have weekly community meetings jointly facilitated by a service user involvement worker and staff (excluding Laurel); Evidence that all acute wards have a dedicated STR worker; and Evidence that all wards have completed actions in Triangle of Care July % July % October % January % March %

19 self-assessment. Total 100%

20 North Somerset - CCG Local CQUIN Indicator number North Somerset local 1 Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Physical and Mental Health Partnership working 0.5 % of contract value (0.2% of total CQUIN value) 1. Partnership working with NSCP to enhance the physical health care for patients in mental health services, and to ensure the physical health needs of service users are identified, assessed and met. This builds on the CQUIN from 2014/15. This will include as a minimum an equivalent of a total of one day per week (4 days per month) spent for each organisation working directly with the other directly supporting patient care/problem solving/case management. The two providers (AWP and NSCP) will work together to agree specific implementation plan for this CQUIN. Once agreed between the providers, the commissioners will sign off. 2. For NSCP and AWP to continue to offer bespoke reciprocal training to support the up-skilling each other s workforce in identifying, assessing and supporting the provision of mental health and physical health care respectively. Numerator 1 A total of 40 clinical days (or 80 half days) per year to be spent working directly with NSCP in a variety of teams, settings and services, which have been identified as providing the highest possible impact in terms of upskilling staff, enhancing the patient pathway and promoting best practice. These days should be evenly spread throughout the year and agreed with NSCP in advance. 2 AWP will run a minimum of 2 whole day general training sessions for NSCP (similar to the ones agreed in 2014/15). AWP will ensure attendance levels for any training offered, agreed and provided by NSCP are met. In addition to this, they will run 4 further smaller sessions targeted to specific training needs identified within NSCP (eg dementia training within Clevedon Hospital). Denominator Rationale for inclusion Data source NA Continue to develop strong partnership working To broaden the potential intended benefit of national CQUIN 4 (improving physical healthcare to reduce premature mortality in people with severe mental illness) to other mental health groups To ensure mental health needs of patients in community services are considered and addressed To improve health outcomes across the mental and physical health domains Quarterly reports on progress to the contract meetings.

21 Frequency of data collection Organisation responsible for data collection Frequency of reporting to Commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? Ongoing AWP Quarterly See milestones set out below NA Q4 See milestones below February 2016 Quarterly milestones will have to be achieved for the providers to qualify for payment at the end of each quarter Because a stepped approach is planned, payment will only be made for achievement of each milestone

22 Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 Plan for implementation of CQUIN agreed between the providers and signed off by the commissioners. End Q1 2015/16 25% A schedule for reciprocal working will be agreed and implemented. Providers will be expected to demonstrate that plans are in place within appropriate teams to ensure that this time is being used to achieve maximal impact in delivery of high quality clinical care. Providers will agree a training plan to meet element 2 of the CQUIN, and will identify the groups of staff and subject matter for the targeting training. Quarter 2 Quarter 3 Progress against CQUIN to be reported Evidence of reciprocal working arrangement. Training programme in place and on track according to plan. Progress against CQUIN to be reported Evidence of reciprocal working. Training programme in place and on track according to plan. End Q2 2015/16 End Q3 2015/16 25% 25% Quarter 4 Final report and evaluation to be completed. During Q4 2015/16 25%

23 North Somerset CCG Local CQUIN Indicator number North Somerset Local 2 Indicator name Indicator weighting Borderline Personality Disorder service set up 0.89% of total contract value (% of CQUIN scheme available) Description of indicator Establish a Borderline Personality Disorder (BPD) which will: Facilitate early identification of people with personality difficulties and provide rapid access to assessment and formulation of these difficulties Provide a clear and evidence based framework for engaging with and responding to patient need Allow access to a range of effective evidence based therapeutic interventions Be provided by staff with the specialist skills and knowledge to manage this cohort of patients effectively Work closely with PositiveStep service to ensure a seamless, needs led approach Ensure early access for young people to the service by working closely with CAMHS and developing a pathway for people aged 14 upwards Develop further the findings from the AWP bed review to ensure appropriate processes, systems and interventions are in place to proactively manage any need for inpatient admissions amongst the BPD population Create a BPD co-ordinator post locally Numerator Not applicable for 15/16. To be agreed for 16/17 Denominator Rationale for inclusion Data source Frequency of data collection Organisation NA There is a growing evidence base for providing a specialist and unique BPD service to ensure best outcomes for patients and to ensure appropriate use of and access to MH services. Patients with BPD are costly to the CCG in use of specialist placements and other inpatient facilities. North Somerset CCG is investing in a new BPD service in 2015/16, and this CQUIN is to pump prime this new service to facilitate quicker implementation of the strategy, develop the workforce and ensure that the service can develop robust, evidence based and clinically efficient processes, systems and services to best meet the needs of this cohort of patients. AWP RIO Ongoing AWP

24 responsible for data collection Frequency of reporting to Commissioner Quarterly Baseline period/date 2014/15 Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? Q4 See milestones set out below March 2015 Milestones must be met to qualify for payment Payment will only be made for milestones that have been met

25 Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 Develop project plan for implementation of the BPD service and sign off with commissioners. Baseline audit of current BPD inpatient activity Recruit staff as appropriate Develop workforce July % Quarter 2 & 3 Ongoing implementation of project plan and service October 2015 & January % Quarter 4 Evaluation of service implementation to include achievement of targets and priorities for service development in 2016/17 Work with Commissioners to develop 2016/17 CQUIN to build on 15/16 CQUIN March % NB this CQUIN will be continued into 2016/17. The detail of the 2016/17 CQUIN will be based on initial findings from the 2015/16 CQUIN

26 North Somerset CCG - Local CQUIN Indicator number North Somerset local 3 Indicator name Indicator weighting BASS Wait List initiative 0.16 % of contract value (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to Commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) BASS waitlist initiative to increase assessment and diagnostic capacity within existing service, thereby pump priming the new recurrent funding to reduce the wait time from 9 months to under 3 months. The additional funding is expected to fund an additional 12 assessments in year (in additional to 74 per annum from the recurrent funding). Number of people who have been seen under the wait list initiative Number of North Somerset residents on the wait list for the BASS diagnostic service 2015/16 Current wait list is in excess of 42 weeks. With a steady increase in referrals, additional recurrent funding has been agreed for this service, however it will not be possible to bring the wait list down to an acceptable level quickly without additional short term funding to clear the back log. This CQUIN therefore pump primes the new investment to the service. AWP wait list management system On going AWP Quarterly NA NA Q4 See milestones below Final indicator March 2016

27 reporting date Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? Activity must be spread throughout the year to ensure impact on wait list as soon as possible, allowing for some lead time for staff recruitment no Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 Recruit additional staff required Plan activity June 15 25% Quarters 2, 3 & 4 Implement activity plan Quarterly intervals 75%

28 North Somerset CCG - Local CQUIN Indicator number North Somerset local 4 Indicator name Indicator weighting (% of CQUIN scheme available) Smoking Cessation 0.15 % of contract value, with an additional 23,000 funded from NSC public health upon achievement of the CQUIN (6% of total CQUIN value) Description of indicator Implement NICE 48 Guidance and move towards the ambition to become smoke free on the Longfox site. This is applicable for staff and patients. This will include providing dedicated resource to lead on this initiative in North Somerset. Additional key deliverables are: Perform the baseline audit tool at year start and year end Implementing national guidance Developing and implementing local policies and procedures Developing processes to ensure that patients are appropriately followed up and supported in their smoking cessation on discharge Supporting staff and patients to quit smoking or reduce their tobacco use Provide smoking cessation services consistent with the latest NICE guidance in NHS Stop Smoking Services: Service and Monitoring Guidance Service and Monitoring Guidance 2014 including North Somerset Harm Reduction protocols 1 Co-ordinate training for staff To ensure a minimum of 5 fully trained advisors (this training will be provided by Public Health) All patient facing staff 2 (including Drs, therapists and nurses) will be trained to deliver brief intervention training. Provision of patient and staff information, including smokefree signage, information leaflets and information on the website The specific indicators based on the national guidance are attached as appendix one, and are expected to be fully met under the conditions of this CQUIN. NB AWP will be expected to meet the costs of pharmacotherapy for all inpatients. Staff who wish to quit can access the service provided by AWP on site, or can be signposted to existing community services. Staff requiring pharmacotherapy will be signposted to community smoking cessation services for access to this. Numerator The approximate of number of inpatient service users on the Longfox 1 Protocols and policies will be made available at training and should be widely available/circulated to appropriate staff groups 2 Defined as staff who regularly come into contact with patients, and will include all clinical staff, receptionists and some admin staff

29 site is 418 per annum 3. It is estimated that 90% of these smoke, and that 70% of the smoking population will want to quit, with 10% of these being motivated to quit now. This gives an indicative numerator of 26 people. The detailed performance indicators are detailed in Appendix 1 Denominator Rationale for inclusion The target for supporting patients to quit in 2015/16 is 13, which allows lead time for staff training. Support the NHS Smoke Free Tobacco control initiative Ensure compliance with NICE guidance Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to Commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? Quarterly reports on progress to the contract meetings. Ongoing AWP Quarterly See milestones set out below NA Q4 See milestones below March 2016 Quarterly milestones will have to be achieved for the providers to qualify for payment at the end of each quarter Because a stepped approach is planned, payment will only be made for achievement of each milestone 3 Based on admission figures 2013/14

30 Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 Quarter 2 Quarter 3&4 Lead identified. Baseline audit completed for inpatients and staff Process in place to capture smoking status and brief intervention prompt Pharmocotherapy readily available on wards, with protocols in place Training minimum of 3 level 2 staff 30% of staff to have had brief intervention training by end Q2. Smoking status recorded on 99% of all new admissions Policies and procedures agreed internally Formally agreed processes in place for supporting staff to stop smoking Patient and staff information leaflets in place Longfox site fully compliant with NICE guidance 48. Minimum additional 2 staff trained to level 2 Strategy in place for on going work to support smoking cessation or reduction. Satisfactory achievement against the performance indicators in appendix 1 July % October % March % NB Public health contact will be Natalie Simms (natalie.simms@n-somerset.gov.uk)

31 North Somerset CCG - Local CQUIN CQUIN number North Somerset Local 5 Indicator name Indicator weighting AWP Pathway for service users with LD 0.05 % of contract value (% of CQUIN scheme available) Description of indicator Enhance the mental health pathway for service users with LD by 1. Ensuring staff working within AWP are sufficiently skilled to work with people with a learning disability who also have a mental health condition 2. Ensuring that reasonable adjustments are made in mainstream mental health services for people with LD. 3. AWP completing the Green Light assessment tool and implementing the recommendations arising from the assessment tool 4. AWP supporting implementation of the new monthly LD/MH operational meetings monthly attendance 5. AWP staff to attending Green Light Forum meetings 6. Having a named strategic lead and/or clinical lead for the LD pathway within AWP Numerator Denominator Rationale for inclusion NA 1. Complete a training needs assessment of AWP staff who work with people with a learning disability. 2. Develop and implement an action plan based on the training needs assessment 3. Completion of green light assessment tool 4. Attendance at 12 operational meetings per year 5. Attendance at 2 Green Light Forum meetings per year. 6. Named AWP LD Lead Access to mainstream services is crucial for people with LD to ensure equal and equitable access to specialist care. This CQUIN will support AWP in meeting the needs of individuals with LD. It will embed some changes, training and processes in year for a sustainable longer-term impact. It will help support the CCGs aim to ensure a holistic approach to meeting the physical and mental health needs of our population and ambition to improve health outcomes for people with LD and people with mental health problems. To achieve this, it is essential that staff in mental health services have a good working knowledge of the needs of people with a learning disability and also a mental health condition. Data source Frequency of data Quarterly reports on progress to the contract meetings. Ongoing

32 collection Organisation responsible for data collection Frequency of reporting to Commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment Are there any rules for partial achievement of the indicator at the final indicator period/date? AWP / NSCP Quarterly See milestones set out below NA Q4 See milestones below February 2016 Quarterly milestones will have to be achieved for the providers to qualify for payment at the end of each quarter Payment will only be made for achievement of each milestone

33 Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Milestone weighting (% of CQUIN scheme available) Quarter 1 To undertake a needs assessment of AWP staff to identify training needs for AWP staff. End Q1 2015/16 25% Develop an action plan to address identified training needs. Evidence of attendance at monthly LD/MH operational meetings Identify LD lead Quarter 2 Evidence of implementation of action plan. Attendance at operational meetings and Green light forum meeting. End Q2 2015/16 25% Quarter 3 Completion of the Green Light Assessment Tool and development of action plan identifying action that needs to be taken to comply with the assessment tool. Evidence of progress against needs assessment action plan End Q3 2015/16 25% Evidence of progress against Green Light Assessment Tool action plan. Quarter 4 Attendance at operational meetings. Completion of action plan. Production of final report / evaluation Q4 2015/16 25%

34 South Gloucestershire CCG Local CQUINs Indicator number 1. Indicator name Cognitive Behavioural Therapy for Psychosis (CBTp). Indicator weighting (% of CQUIN scheme available) Description of indicator Early warning signs of psychotic relapse. 66k This CQUIN will focus on enhancing the service provided to people with a diagnosis of psychosis & schizophrenia to manage relapse and promote & enhance recovery In line with Clinical research findings & NICE compliance, the work will focus on: Early warning signs and relapse prevention CBT(p) for people with psychosis & schizophrenia Numerator a) The number of open cases within the locality of people experiencing psychosis or schizophrenia who have a clearly documented and agreed Early Warning and Relapse plan b) The number of open cases within the locality where manualised CBT is being delivered to people with a psychotic or schizophrenic illness Denominator The number of open cases within the locality of people experiencing psychosis or schizophrenia Rationale for inclusion Local CQUIN B J Psych March Schizophrenia: Early Warning signs. NICE Guidance Feb 2014: treatment and management of Psychosis and Schizophrenia. (Section 1.3.7) Data source Local data collection Data will also be collected using the Royal College of Psychiatrists' National audit of schizophrenia- Audit of practice tool (questions 42 and 44) Frequency of data collection Monthly Organisation responsible for data Provider collection Frequency of reporting to Quarterly commissioner Baseline period/date Not applicable Baseline value March 2015 Final indicator period/date (on March 2016 which payment is based) Final indicator value (payment threshold) Final indicator reporting date March 2016 Are there rules for any agreed inyear milestones that result in payment?

35 Are there any rules for partial achievement of the indicator at the final indicator period/date? Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Quarter 1 Baseline data collection number of staff who have undertaken EWS training Agreement of Q3 improvement trajectory with CCG (75% provisionally agreed) Delivery of manualised CBT in Psychosis and Schizophrenia Identifying training pathway and progress staff onto this pathway to deliver CBT in Psychosis ( in line with locality strategy) Plan locality work around strengthening and enhancing Early Warning and Relapse plan intervention Quarter 2 Increase the number of people with Psychosis or Schizophrenia who have access to CBT (p) Plan locality initiative around enhancing staff skills in regard to Early Warning and Relapse Planning Quarter 3 Deliver initiative around staff skills and early warning By the end of the Quarter 75% of Recovery Staff will have undertaken Early Warning Signs training (This percentage to be confirmed at the end of Q1 when baseline has been established) Support identified staff to commence CBT (p) training in line with locality strategy Maintain delivery of CBT (p) Date milestone to be reported July % October % January % Milestone weighting (% of CQUIN scheme available)

36 Rules for partial achievement at final indicator period/date Final indicator value for the partial % of CQUIN scheme available for meeting final achievement threshold indicator value Manualised CBT delivered 25% Manualised CBT delivered 25% Manualised CBT delivered 25% EWS Training initiative deliver Manualised CBT delivered 25% Qualitative review of EWS work undertaken

37 Indicator number 4 Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Indicator Intensive service for older adults with functional illness 0.5% - 74k The CQUIN will focus on services to older adults who are experiencing an episode of acute functional illness and are vulnerable to hospital admission or who could be supported to return home following hospital admission See quarterly reports See quarterly reports At the beginning of Q3 in 2014 the SG Intensive team (IST) started to engage with work in relation to older adults with a functional illness who were presenting with acute need. The intention was to recruit additional staff to support this work and this has been challenging but is underway again. In the meanwhile the team started to roll out their work with the older adult cohort and early indicators showed a promising start but brings with it challenges around changing cultural practice and further time would be an asset to build on this work. Objectives of CQUIN for 2015/16: - Produce functional older adult care and treatment pathways by ICD 10 group - Increase the number of older adults with an acute presentation of functional illness who have contact with the Intensive support team - Reduce functional older adult LOS - Introduce facilitated early discharge with IST support Data source Trust reported data on LOS Out of hours activity reporting for South Glos IST Trust reported data on access and demographics for South Glos IST Frequency of data collection Daily Organisation responsible for data AWP provider collection Frequency of reporting to Quarterly commissioner Baseline period/date March 2014 April 2015 LOS median and mean Baseline value Final indicator period/date (on which March 2015 January 2016 LOS median and mean payment is based) Final indicator value (payment threshold)

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