1. Independence and self-management Patients able to self-manage Education on self- management % patients feeling confident or supported (7) Falls – acute admissions % permanent admissions to residential care Staff resource Key worker identified and known to patient E-Rostering data, sickness absence Training levels/skills Duration of service, turnover rates Multi-agency care provision Other profession input in care plan % pts with multi- agency care input Agency/bank use by geography Effective care planning Care plan clearly recorded in notes Review of treatment plan in notes Engagement of >30% service users in plan (28) Home equipment in place in time Dependency and complex needs Barthel ADL Index(111) Complex co- morbid conditions (e.g. dementia) Patient popn demographics (DPI/Age ) Size/acuity of caseload by staff level Appropriate referrals Time to assessment from referral <24hrs Discharge in line with standards (TCS 41) CCT rehab team accept discharge plan (36) Propn patients assessed within 72 hrs discharge Unplanned admissions/change to dwelling due to crises in community-treated cohort; % of patients and/or carers feeling supported Community nursing (1) OVERARCHING OUTCOME PREDICTIVE FACTORS MEASURES

2. Prevention of health crises and functional deterioration Pts/carers able to self-manage Carer/patient education on self- management % patients and carers feeling confident and supported (TCS 27) % care plans in partnership with carer/family Reduced LOS/ unplanned admissions LOS data for community hospitals Unplanned acute admissions in SHFT pt cohort Unplanned acute LOS in SHFT pt cohort/ LTCs Minimise falls, pain, respiratory distress, UTIs Informed out of hours/GP services/SCAS Ability to share records across agencies Rapid response service 24 hours Multi-agency working in care plan GP unplanned admissions rate Monitoring of long–term conditions Care plan % in place >12 months in notes Review of treatment plan in notes % newly acquired gde 3/4 pressure ulcers Holistic needs assessment to identify risk of deterioration Dependency and complex needs Barthel ADL Index (111) % catheterised % end of life % LTCs Patient popn demographics (DPI/Age ) % in residential or nursing care Appropriate caseload/ referrals Assessment to referral <24hrs (TCS 36) Use of appropriate referral criteria % inappropriate referrals (TCS) CCT rehab team accept discharge plan (36) Risk profiling to detect 1%/5% caseload Re-admissions to acute care in <30 days in CCT/virtual ward treated cohort (TCS 31) Community nursing (2) OVERARCHING OUTCOME PREDICTIVE FACTORS MEASURES Red n in unplanned acute admissions in CCT/virtual ward treated cohort (TCS 19, 32)

3. Maintain patient safety Communication and information % pts with LTC with named care coordinator % pts with exacerbation plan conditions Patient safety incident reporting % newly acquired pressure ulcers Staffing levels and skill mix Benchmarking data WTE’s by band E-Rostering data, sickness absence Routine pts seen within 3-5 days Duration of service, turnover rates Equipment Order early Stock up to date Delivery within 4 hours Patient choices % patients feel safe and secure Engagement of >30% service users in plan % choice of place of care/death in care plan % carers consulted about patient care Dependency and complex needs % catheterised % end of life Patient popn demographics (DPI/Age ) % in residential or nursing care Environment Geographical distance or isolation Layout and accessibility for caring Infection control compliant Standards of environment Community nursing (3) OVERARCHING OUTCOME PREDICTIVE FACTORS MEASURES