In year 1 (15/16) these outcomes will be measured as outlined below and baselines established from robust data for each indicator.

Transcription

1 7. Key Performance Indicators (KPIs) (s These KPIs have been selected to demonstrate that care planning in Hillingdon improves patient experience of care, patient s quality of life and improves health and care outcomes over the 3 year period of the contract. In year 1 (15/16) these outcomes will be measured as outlined below and baselines established from robust data for each indicator. The CCG recognizes this is the first contract that has been developed with based on achieving outcomes, therefore these measures require testing and validating. Networks are expected to demonstrate they are achieving benefits for patients outlined below, but for the purpose of receiving the performance, 15/16 will be treated as a shadow year. The is indicative for subsequent years and will not be applied in the shadow year. To receive the performance, networks will be required to: Establish baselines that demonstrate patient benefits Work with the HCCG to test and validate performance measures including patient and staff experience measures. Demonstrate impact of care planning on non-elective activity at network level. Confirm that accurate monitoring can be achieved in Years 2 and 3 of the contract. Version Final /05/15 1

2 1 Improved patient experience - Self reported I statements (as part of patient surveys / interviews) 20% 2 Proportion of people who have achieved jointly agreed goals. Aspiration is to achieve 70% patients / carers suggest satisfactory experience (exact threshold to be set once design of questionnaire is finalized) Aspiration is to achieve 70% patients / carers suggest satisfactory experience (exact threshold to be set once design of questionnaire is finalized) 80% 85% Results from an agreed patient/carer survey (One validated questionnaire to be used across Hillingdon which will incorporate elements of PAM) Methodology to be agreed by service commencement aligned with work by Comm s and Engagement team. Proposed 40% sample size cohort to be selected by commissioner 80% 85% Results from patient / carer survey (One questionnaire to be used across Hillingdon which will incorporate elements of PAM) 40% sample size cohort to be selected by commissioner Methodology to be agreed by service commencement. 10% 3 Proportion of patients who have care planning where there is tangible improvement in quality of life and level of independence Measured using an agreed validated screening tool as part of regular reviews. This indicator is applicable only for those who have completed care plans. 40% sample size cohort to be selected by commissioner 10% Version Final /05/15 2

3 4a Reduction in total nonelective admissions (general & acute), for age 65 years and over. 4b Reduction in total nonelective admissions (general & acute), for 65 years and over, for the population cohort with care planning. 2.6 % reduction which equates to 288 episodes for all Hillingdon practices. Practices trajectory to be supplied. Q SUS data analysis. Indicator to be measured against expected growth for the population 65 years and over. CCG will provide data at practice and network level on a monthly basis with progress against trajectory SUS data analysis. Indicator to be measured against expected growth for the particular cohort of population in that network. Following MDTs and other care planning processes a tracker report will be sent to the informatics team to enable an identifying flag to be used. This process has been developed by the pilot and the tracker format will be supplied. 7% sample size cohort to be selected by commissioner for audit. The review will be undertaken quarterly 20% 5% 5 Reduction in urgent care 0.5% reduction on trend of TBC TBC SUS data analysis. Indicator to be 15% Version Final /05/15 3

4 demand: UCC and A&E attendances, for 65 years and over, with care plans. 6 Proportion of people in residential/nursing care who have not been assessed / reviewed by the Integrated care team within the last 3 months following a nonelective attendance. episodes by practice Aspire to 20% (most people in residential care should have been reviewed). measured against expected growth for the 65 years and over population. Following MDTs and other care planning processes a tracker report will be sent to the informatics team to enable an identifying flag to be used. This process has been developed by the pilot and the tracker format will be supplied. The review will be undertaken quarterly 10% 0 Following MDTs and other care planning processes a tracker report will be sent to the informatics team to enable an identifying flag to be used. This process has been developed by the pilot and the tracker format will be supplied. The date of the care planning will be taken into account and an exception report will be sent to the networks for investigation and reporting back to the CCG on mitigating circumstances and/or remedial actions. 15% 7 Proportion of people admitted in hospital for any Ambulatory care sensitive TBC TBC SUS data analysis on non-elective 5% for 7, 8, 9 admissions for ACSC or NHS England list of avoidable Version Final /05/15 4

5 condition (ACSC) who have been assessed / reviewed by the Integrated care team within 4 weeks following attendance or admission. 8 Subjective reviews - sample 10 patient journeys 9 Improved staff experience: % of professionals who strongly agree or agree that they are working in an emergency admissions, (to be selected by CCG, composite measure) to be mapped against reviews / assessments done in respective IC networks. Following MDTs and other care panning processes a tracker report will be sent which enables an identifying flag to be used. This process has been developed by the pilot and the tracker format will be supplied. The date of the care planning will be taken into account and an exception report will be sent to the networks for investigation and reporting back to the CCG on mitigating circumstances and/or remedial actions. Reflective learning tool to inform 5% for 7, 8, 9 an annual learning event and development of year 2/3 ICP and reconfiguration of services to N/A address changes required or gaps. To be undertaken annually. TBC TBC Results from survey of primary care 5% for 7,8,9 professionals and those working on integrated care planning with primary care networks. Version Final /05/15 5

6 integrated way to support patients and carers - % of professionals who strongly agree or agree that they deliver the care and support that they aspire to Indicators (KPIs (Sample size to be agreed). To be undertaken annually. Version Final /05/15 6