1. 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

2. 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