Community hospitals (1) OVERARCHING OUTCOME PREDICTIVE FACTORS Safe and timely discharge/transfer to appropriate care Environment ready Home visit by OT/ AHP risk assessment Continuing /Palliative care provision/funds Equipment in place (TCS 35) Appropriate dwelling Patient and carer ready for discharge Planned discharge with MDT To Take Outs/Rx ready and dispensed Adequate discharge summary and info Social care assessment Resources Timely access to CCT/social care resources Transport available GP/ clinical specialist input Availability of acute/NH/ res/hospice beds Dependency/ RAG Staff resourced in line with need/ skills mix Barthel ADL Index (Cochrane) Patient popn demographics (DPI/Age ) MMSE mental health Aligned expectations of service Carer perceptions aligned to service GP and acute care understanding of referral criteria Use of appropriate referral criteria % inappropriate referrals (TCS) DTOC/LOS Readmission in same pt cohort within 28 days of discharge (PHOF) MEASURES

Community hospitals (2) OVERARCHING OUTCOME Provide high-quality care to achieve individual goals Holistic Assessment Specialist staff input Comprehensive MDT assessment process Timely access to diagnostics Risk assessment Individualised care planning MDT multi agency input to care plan Monitoring and regular review Patient and carer involvement Named nurse/ primary team Skilled staff resource Right skill mix and resource on ward GP/Clinical Specialist on site Flexible/adaptable workforce Trained staff Quality environment Infection control/ hygiene Equipment provision Access to fluids and nutrition Minimise risk of falls Monitoring for patient safety Intentional rounding and review Medicines management VTE/ Pressure ulcers Mental health/cognition Patient and carer satisfaction SIRIs PREDICTIVE FACTORS MEASURES