emergency bed days in 12/13. Yet we know that between 20% and 30% of hospital admissions in this group could be prevented by proactive case finding, frailty assessment, care planning and use of services outside of hospital (Mytton et al 2012). The problem we face is that people with frailty are currently either not reliably identified or identified only when advanced frailty has developed. This to missed opportunities to mitigate the preventative components of frailty, to instigate proactive care models such as personalised care and support planning, and/or target geriatric resources. Data source A clinical record of a representative sample of patients aged 75 and over who had a frailty syndrome (see further guidance). Existing GP Practice Read Codes are available to ‘flag’ people diagnosed with frailty. This information would contribute to case finding systems and care planning for practice population at risk of unplanned admission. Frequency of data collection Quarterly Organisation responsible for data collection Provider Frequency of reporting to commissioner Quarterly Baseline period/date Q1 2016/17 Baseline To be determined by baseline audit Final indicator period/date (on which payment is based) Q4 2016/17 Final indicator value (payment threshold) The indicator values for payment are to be agreed locally, and will represent an achievable but stretching level of improvement from the baseline to what should be 95% or above achievement of each of the indicators.
Final indicator value for the partial achievement threshold % of scheme available for meeting final indicator value Supporting Guidance and References Background Broadly there are 5 frailty syndromes and encountering one of these should raise suspicion that the individual concerned has frailty. However, it is possible to have any of these problems without frailty and sometimes there can be a very straightforward explanation for the problem. Falls (e.g. collapse, legs gave way, ‘found lying on floor’). Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck in toilet’). Delirium (e.g. acute confusion, ’muddledness’, sudden worsening of confusion in someone with previous dementia or known memory loss). Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence).
Are there any rules for partial achievement of the indicator at the final indicator period/date? To be agreed locally EXIT Route To be agreed locally 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 Quarter 4 for Partial Achievement at Final Indicator Period/ Date indicator value for the partial achievement threshold % of CQUIN scheme available for meeting final indicator value
indicator period/date (on which payment is based) To be determined from baseline audit. indicator value (payment threshold) Q4 2016/17 Final indicator reporting date To be agreed locally that represents a stretching but achievable rate of improvement from baseline. Are there rules for any agreed in-year milestones that result in payment? To be agreed locally Are there any rules for partial achievement of the indicator at the final indicator period/date? To be agreed locally EXIT To be agreed locally Milestones
Date/period milestone relates to 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 Quarter 4 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 Supporting Guidance and References 24. Acute Kidney Injury
discharge summaries Supporting Guidance and References Draft format for local data collection Tick column below if stage of AKI is recorded in discharge letter Tick column below if information on medicines review having been undertaken is recorded in discharge letter Tick column below if type of blood tests required on discharge for monitoring are recorded in discharge letter Tick column below if frequency of blood tests required on discharge for monitoring are recorded in discharge letter