Somerset Partnership NHS Foundation Trust CQUINS 2014/15
Transcription
Somerset Partnership NHS Foundation Trust CQUINS 2014/15
Somerset Partnership NHS Foundation Trust CQUINS 2014/15 FRIENDS AND FAMILY TEST – IMPLEMENTATION OF STAFF FRIENDS AND FAMILY TEST Indicator number 1.1 Indicator name Friends and Family Test – Implementation of Staff Friends and Family Test Indicator weighting (% of CQUIN scheme available) Description of indicator 0.0625 Numerator Implementation of staff Friends and Family Test as per guidance, according to the national timetable Not applicable Denominator Not applicable Rationale for inclusion National CQUIN scheme Data source Local provider response to local commissioners Frequency of data collection Check on implementation at end of June 2014 Organisation responsible for data collection Provider Frequency of reporting to commissioner One off Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) Q1 2014/15 Final indicator value (payment threshold) Provider to demonstrate to commissioner that staff Friends and Family Test has been delivered across all staff groups as outlined in guidance Final indicator reporting date Response from providers to commissioners by 30 June 2014 Are there rules for any agreed in-year milestones that result in payment? Funding payable once June 2014 indicator achieved Are there any rules for partial achievement of the indicator at the final Not applicable indicator period/date? FRIENDS AND FAMILY TEST: EARLY IMPLEMENTATION Indicator number 1.2 Indicator name Friends and Family Test – Early Implementation in Mental Health Inpatient Settings Indicator weighting (% of CQUIN scheme available) 0.0625 Description of indicator Early implementation Numerator Not applicable Denominator Not applicable Rationale for inclusion National CQUIN scheme Data source Local provider response to local commissioners Frequency of data collection Check on implementation at end of October 2014 Organisation responsible for data collection Provider Frequency of reporting to commissioner One off Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) October 2014 Final indicator value (payment threshold) Full delivery of Friends and Family Test across all services delivered by the provider as outlined in guidance Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Provider to demonstrate to commissioner that milestone has been met Final indicator reporting date Response from providers to commissioners by 31 October 2014 Are there rules for any agreed in-year Not applicable milestones that result in payment? Are there any rules for partial achievement of the indicator at the final indicator period/date? Partial implementation will result in receiving half of the funding available for the indicator (20% of the FFT CQUIN). There will be further guidance on the conditions for partial funding FRIENDS AND FAMILY TEST: INCREASED RESPONSE RATE FFT IN INPATIENT SETTINGS Indicator number 1.3a Indicator name Friends and Family Test – Increased or Maintained Response Rate; Community Hospital inpatient settings Indicator weighting 0.1667 (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Increased or maintained response rate Not applicable Not applicable National CQUIN scheme Provider submission Monthly return Provider Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Data available by end of April 2015 (for Q4) Yes – see below Are there any rules for partial achievement of the indicator at the final indicator period/date? No Monthly See below See below Q4 in 2014/15 A response rate for Quarter 4 that is at least 30% for inpatient services Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Quarter 1 A response rate for Quarter 1 that is at least 25% for inpatient services A response rate for Quarter 4 that is at least 30% for inpatient services 31 July 2014 Milestone weighting (% of CQUIN scheme available) 50% 30 April 2015 50% Quarter 4 FRIENDS AND FAMILY TEST: INCREASED RESPONSE RATE FFT IN MIU SETTINGS Indicator number Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) 1.3b Friends and Family Test – Increased or Maintained Response Rate; MIU Settings 0.1667 Increased or maintained response rate Not applicable Not applicable National CQUIN scheme Provider submission Monthly return Provider Monthly See below See below Q4 in 2014/15 A response rate for Quarter 4 that is at least 20% for A&E services Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Data available by end of April 2015 (for Q4) Yes – see below Are there any rules for partial achievement of the indicator at the final indicator period/date? No Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner) Date milestone to be reported Quarter 1 A response rate for Quarter 1 that is at least 15% for A&E services A response rate for Quarter 4 that is at least 20% for A&E services 31 July 2014 Milestone weighting (% of CQUIN scheme available) 50% 30 April 2015 50% Quarter 4 FRIENDS AND FAMILY TEST: REDUCING NEGATIVE RESPONSES Indicator number Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) 1.3c Friends and Family Test – Reducing negative response rates from inpatient and MIU settings 0.1667 Reduction in negative response rates as a proportion of overall responses Not applicable Not applicable National CQUIN scheme Provider submission Monthly return Provider Monthly Overall negative response rate for 2013/14 TBC Q4 in 2014/15 A response rate for Quarter 4 that is lower than the baseline value Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Data available by end of April 2015 (for Q4) No Are there any rules for partial achievement of the indicator at the final indicator period/date? No Indicator number Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date 2.1 Reduction In Pressure Ulcer Incidence in Community Hospital inpatients and on the District Nurse caseload (excluding patients resident in a care home) 0.2500 To reduce the reported incidence of people with an avoidable healthcare acquired pressure ulcer (Grade 2 and above) in: 1) inpatient beds by 40% by the end of Quarter 4 2) community setting by 15% by the end of Quarter 4 Number of Pressure Ulcers (Grade 2 and above) identified by the provider 1) Baseline position for 2013/14 2) Baseline position for 2013/14 It was estimated in 2004 that the NHS spent £2.1bn treating pressure ulcers. These figures are a conservative estimate. 90% of this cost is nursing time. Evidence suggests that between 4 and 10% of patients admitted to UK district hospitals develop a pressure ulcer. Monthly analysis of reported incidents reported via risk management systems and quality dashboards Monthly Provider Baseline value Quarterly report on Quality/CQUIN scorecard to Quality Review Meeting 1) Baseline position for 2013/14 2) Baseline position for 2013/14 N/A Final indicator period/date (on which payment is based) Payment is split into two 6-monthly periods with 50% of the total annual available payment being available for each 6 month period Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment? Are there any rules for 1) A 40% overall reduction by Q4 2) A 15% overall reduction by Q4 Commissioners will satisfy themselves that the data submitted accurately reflects the position within the provider organisation 31 March 2014 Performance against the improvement goal will be reviewed at 6 months. Payment will be achieved if final targets are met. 1) partial achievement of the indicator at the final indicator period/date? 9% reduction or less = 0% of CQUIN value 10- 29% reduction = 30% of CQUIN value 30- 39% reduction = 60% of CQUIN value 40% or greater reduction = 100% of CQUIN value 2) 4% reduction or less = 0% of CQUIN value 5 – 9% reduction = 30% of CQUIN value 10 – 14% reduction = 60% of CQUIN value 15% or greater reduction = 100% of CQUIN value Milestones Date/period milestone relates to Quarter 2 Quarter 4 Rules for achievement of milestones (including evidence to be supplied to Commissioner) Performance against the improvement goal will be reviewed at 6 months (end of Quarter 2). Payment will be achieved if 6 month target is met. Payment will be achieved if final targets are met. Date milestone to be reported Quarter 2 CQRM Milestone weighting (% of CQUIN scheme available) 50% Quarter 4 CQRM 50% Rules for partial achievement at final indicator period/date Final indicator value for the part achievement threshold % of CQUIN scheme available for meeting final indicator value 9% reduction or less in community hospital acquired pressure ulcers 0% 10 – 29% reduction in community hospital acquired pressure ulcers 30% 30 – 39% reduction in community hospital acquired pressure ulcers 60% 40% or greater reduction in community hospital acquired pressure 100% ulcers 4% reduction or less in community DN caseload acquired pressure 0% ulcers 5- 9% reduction in community DN Caseload acquired pressure 30% ulcers 10- 14% reduction in community DN Caseload acquired pressure 60% ulcers 15% or greater reduction in community DN Caseload acquired 100% pressure ulcers PRESSURE ULCERS: REDUCTION IN PREVALENCE Indicator number 2.2 Indicator name Pressure Ulcer Prevention Indicator weighting (% of CQUIN scheme available) 0.2500 Description of indicator To identify the top ten sources of non-trust acquired pressure ulcers (grade 2 – 4) within Somerset Partnership Patient Population then work collaboratively with these agencies/organisations to raise awareness and assess the effectiveness of the collaboration by a reduction in PU. Numerator Number of pressure ulcers identified by top ten sources of non-trust acquired pressure ulcers (grade 2 – 4) within Somerset Partnership Patient Population at the end of Q4 2014/15 Denominator Number of pressure ulcers identified by top ten sources of non-trust acquired pressure ulcers (grade 2 – 4) within Somerset Partnership Patient Population in Q1 2014/15. Rationale for inclusion To improve prevention of pressure damage across the health community and work collaboratively with other agencies to reduce the prevalence of pressure ulcers and promote a zero tolerance of harm. Data source Provider incidence reporting data Frequency of data collection Ongoing basis Organisation responsible for data collection Provider Frequency of reporting to commissioner Quarterly Baseline period/date Incidence reporting data Q1 2014/15 Baseline value To be confirmed Final indicator period/date (on which payment is based) End of quarter 4 Final indicator value (payment threshold) Implementation of plan Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) As set out below Final indicator reporting date 31 March 2015 Are there rules for any agreed in-year milestones that result in payment? No. To reduce complexity assessment on the CQUIN would be assessed at year end. Are there any rules for partial achievement of the indicator at the final indicator period/date? No Milestones Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to Commissioner) Date milestone to be reported Quarter 1 Confirm top ten sources of non Trust acquired Pressure Ulcers from Q1 2014/15 incidence reporting data. End of Q1 Milestone weighting (% of CQUIN scheme available) 0% Quarter 2 Develop a training and implementation plan. End of Q2 50% Quarter 4 Plan has been delivered End of Q4 50% DEMENTIA – FIND, ASSESS, INVESTIGATE & REFER Indicator number 3.1 Indicator name Dementia – Find, Assess, Investigate and Refer Indicator weighting (% of CQUIN scheme available) 0.0417 Description of indicator The proportion of patients aged 75 and over to whom case finding is applied following emergency admission, the proportion of those identified as potentially having dementia who are appropriately assessed, and the number referred on to specialist services. Each patient admission can be included only once in each indicator but not necessarily in the same month, as the identification, assessment and referral stages may take place in different months Numerator 1) Number of patients >75 admitted as an emergency who are reported as having: known diagnosis of dementia or clinical diagnosis of delirium, or who have been asked the dementia case finding question, excluding those for whom the case finding question cannot be completed for clinical reasons (eg coma). 2) Number of above patients reported as having had a diagnostic assessment including investigations 3) Number of above patients referred for further diagnostic advice in line with local pathways agreed with commissioners Denominator 1) Number of patients >75 admitted as an emergency, with length of stay >72 hours, excluding those for whom the case finding question cannot be completed for clinical reasons (eg coma) 2) Number of above patients with clinical diagnosis of delirium or who answered positively on the dementia case finding question 3) Number of above patients who underwent a diagnostic assessment for dementia in whom the outcome was either positive or inconclusive Rationale for inclusion National CQUIN scheme Data source UNIFY 2 Frequency of data collection Monthly Organisation responsible for data collection Provider Frequency of reporting to commissioner Quarterly Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) April 2014 – March 2015 Final indicator value (payment threshold) 90% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Provider achieves 90% or more for each element of the indicator for Quarter 4 of 2014/15, taken as a whole Final indicator reporting date 30 April 2015 Are there rules for any agreed in-year milestones that result in payment? Yes – see below Are there any rules for partial achievement of the indicator at the final indicator period/date? No Milestones Date/period milestone relates to Rules for achievement of milestones Date (including evidence to be supplied to milestone Commissioner) to be reported Quarter 1 Provider achieves 90% or more for each element of the indicator for 31 July 2014 Milestone weighting (% of CQUIN scheme available) 25% Quarter 1 of 2014/15, taken as a whole Quarter 2 Provider achieves 90% or more for each element of the indicator for Quarter 2 of 2014/15, taken as a whole 31 October 2014 25% Quarter 3 Provider achieves 90% or more for each element of the indicator for Quarter 3 of 2014/15, taken as a whole 31 January 2015 25% Quarter 4 Provider achieves 90% or more for each element of the indicator for Quarter 4 of 2014/15, taken as a whole 30 April 2015 25% DEMENTIA – CLINICAL LEADERSHIP Indicator number 3.2 Indicator name Dementia – Clinical Leadership Indicator weighting (% of CQUIN scheme available) 0.0417 Description of indicator Named lead clinician for dementia and appropriate training for staff Numerator Not applicable Denominator Not applicable Rationale for inclusion National CQUIN scheme Data source Provider Frequency of data collection Annual Organisation responsible for data collection Provider Frequency of reporting to commissioner Twice (pre-April 2014, March 2015) Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) April 2014 – March 2015 Final indicator value (payment threshold) Not applicable Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Provider must confirm named lead clinician and the planned training programme (to be determined locally) for dementia for the coming year. Payment will be made at the end of the year, provided the planned training programme has been undertaken Final indicator reporting date March 2015 Are there rules for any agreed in-year milestones that result in payment? No Are there any rules for partial achievement of the indicator at the final indicator period/date? No DEMENTIA – SUPPORTING CARERS Indicator number 3.3 Indicator name Dementia – Supporting Carers of People with Dementia Indicator weighting (% of CQUIN scheme available) 0.0417 Description of indicator Ensuring carers feel supported Numerator Not applicable Denominator Not applicable Rationale for inclusion National CQUIN scheme Data source Provider report to provider Board Frequency of data collection Quarterly Organisation responsible for data collection Provider Frequency of reporting to commissioner Bi-annually Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) April 2014 – March 2015 Final indicator value (payment threshold) Not applicable Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Provider must demonstrate that they have undertaken a monthly audit of carers of people with dementia to test whether they feel supported and reported the results to the Board. Provider and commissioner should work together to agree the content of the audit Final indicator reporting date March 2015 Are there rules for any agreed in-year milestones that result in payment? No Are there any rules for partial achievement of the indicator at the final indicator period/date? No CARDIO METABOLIC ASSESSMENT FOR PATIENTS WITH SCHIZOPHRENIA Indicator number 4 Indicator name Cardio Metabolic Assessment for Patients with Schizophrenia Indicator weighting (% of CQUIN scheme available) 0.1250 Description of indicator To demonstrate, through a national audit process similar to the National Audit of Schizophrenia, full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in patients with schizophrenia. The audit sample must cover all relevant services provided by the provider. Numerator As set out in the National Audit of Schizophrenia Denominator As set out in the National Audit of Schizophrenia Rationale for inclusion National CQUIN scheme Data source National Audit of Schizophrenia Frequency of data collection One-off, expected to be during Quarter 3 of 2014/15 Organisation responsible for data collection Provider Frequency of reporting to commissioner One-off, through a national audit process, expected to be during Quarter 4 of 2014/15 Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) October – December 2014 Final indicator value (payment threshold) 90.0% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) The provider’s results from a national audit demonstrate that, for 90% of patients audited, the provider has undertaken an assessment of each of the following key cardio metabolic parameters (as per the 'Lester tool'), with the results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions (eg smoking cessation programme, lifestyle advice, medication review, treatment according to NICE guidelines or onward referral to another clinician for assessment, diagnosis, and treatment) The parameters are: Smoking status Lifestyle (including exercise, diet alcohol and drugs) Body Mass Index Blood pressure Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate) Blood lipids Final indicator reporting date 30 April 2015 Are there rules for any agreed in-year milestones that result in payment? No Are there any rules for partial achievement of the indicator at the final indicator period/date? Yes – see below Rules for partial achievement at final indicator period/date Final indicator value for the partial achievement threshold 49.9% or less % of CQUIN scheme available for meeting final indicator value No payment 50.0% to 69.9% 25% payment 70.0% to 79.9% 50% payment 80.0% to 89.9% 75% payment 90.0% or above 100% payment PATIENTS ON THE CPA: COMMUNICATION WITH GENERAL PRACTITIONERS Indicator number 5 Indicator name Patients on the CPA: Communication with General Practitioners Indicator weighting (% of CQUIN scheme available) 0.1250 Description of indicator Completion of a programme of local audit of communication with patents’ GPs, focusing on patients on the CPA, demonstrating by Quarter 4 that, for 90% of patients audited, an up-to-date care plan has been shared with the GP, including ICD codes for all primary and secondary mental and physical health diagnoses, medications prescribed and monitoring requirements, physical health condition and ongoing monitoring and treatment needs Numerator The number of patients in the audit sample for whom the provider has provided to the GP an up-to-date copy of the patient’s care plan, which sets out appropriate details of all of the following: all primary and secondary mental and physical health diagnosis, including ICD codes; medications prescribed and monitoring requirements; and physical health condition and ongoing monitoring and treatment needs Denominator A sample of 100 patients who are subject to the CPA and who have been under the care of the provider for at least 100 days at the time of the audit Rationale for inclusion National CQUIN scheme Data source Local audit Frequency of data collection Two audits, one in Quarter 2, one in Quarter 4 Organisation responsible for data collection Provider Frequency of reporting to commissioner Reports required in respect of Quarter 2 and Quarter 4 Baseline period/date Not applicable Baseline value Not applicable Final indicator period/date (on which payment is based) January – March 2015 Final indicator value (payment threshold) 90.0% Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Quarter 4 audit demonstrates that, for 90% of patients audited during the period, the provider has provided to the GP an up-todate copy of the patient’s care plan, which sets out appropriate details of all of the following: all primary and secondary mental and physical health diagnosis, including ICD codes; medications prescribed and monitoring requirements; and physical health condition and ongoing monitoring and treatment needs Final indicator reporting date 30 April 2015 Are there rules for any agreed in-year milestones that result in payment? Yes – see below Are there any rules for partial achievement of the indicator at the final indicator period/date? Yes – see below Milestones Date/period milestone relates to Rules for achievement of milestones Date (including evidence to be supplied to milestone Commissioner) to be reported Quarter 2 Audit methodology and sampling approach agreed, baseline audit completed and findings reported Final audit demonstrates that, for 90.0% of patients audited during the Quarter 4 31 October 2014 30 April 2015 Milestone weighting (% of CQUIN scheme available) 30% 70% period, the provider has provided to the GP an up-to-date copy of the patient’s care plan, which sets out appropriate details of all of the following: all primary and secondary mental and physical health diagnosis, including ICD codes; medications prescribed and monitoring requirements; and physical health condition and ongoing monitoring and treatment needs Rules for partial achievement at final indicator period/date Final indicator value for the partial achievement threshold 49.9% or less % of CQUIN scheme available for meeting final indicator value No payment 50.0% to 69.9% 25% payment 70.0% to 79.9% 50% payment 80.0% to 89.9% 75% payment 90.0% or above 100% payment CONSULTANT REVIEW OF YOUNG PEOPLE WITH EATING DISORDERS Indicator number 6 Indicator name Consultant Review of young people presenting with Eating Disorder (ED) according to ED Pathway Indicator weighting (% of CQUIN scheme available) 0.5000 Description of indicator Young People 11-18 diagnosed with Anorexia nervosa F50.0 and /or Bulimia F50.2 are seen by a Consultant Psychiatrist within 6 weeks of diagnosis recorded on RiO Numerator Total number of young people diagnosed with Anorexia F50.0 and /or Bulimia F50.2 are seen by a Consultant Psychiatrist within 6 weeks of diagnosis recorded on RiO Denominator Total number of young people recorded on RiO as having been diagnosed with Anorexia F50.0 and /or Bulimia F50.2 Rationale for inclusion Meets NICE Guidelines (CG9)and SOMPAR Eating Disorder Pathway Data source Local provider Response via RiO Frequency of data collection Monthly Organisation responsible for data collection Somerset Partnership NHS Foundation Trust Frequency of reporting to commissioner Quarterly Baseline period/date Q1 Baseline value Q1 as a data collection/baseline setting period, base a trajectory on improving upon the Q1 position. Final indicator period/date (on which payment is based) Q4 - 2014/15 Final indicator value (payment threshold) Outturn level to be established based on trajectory. Rules for calculation of payment due at final indicator period/date (including Achievement of agreed outturn. evidence to be supplied to commissioner) Final indicator reporting date Response from Somerset Partnership NHS Foundation Trust to Commissioner by end April 2015 (Q4) Are there rules for any agreed in-year milestones that result in payment? Quarterly trajectory to be established, based upon baseline data. Are there any rules for partial achievement of the indicator at the final indicator period/date? No Milestones Date/period milestone relates to Rules for achievement of milestones Date (including evidence to be supplied to milestone Commissioner) to be reported Milestone weighting (% of CQUIN scheme available) 25% Quarter 1 Collect baseline data and set trajectory 31 July 2014 Quarter 2 Per trajectory set at the end of Quarter 1 31 October 2014 tba Quarter 3 Per trajectory set at the end of Quarter 1 31 January 2015 tba Quarter 4 Per trajectory set at the end of Quarter 1 30 April 2015 tba ADVANCED CARE/TREATMENT ESCALATION PLANS Indicator number 7 Indicator name Personalised Care Plan for Patients with identified long term conditions (to include frailty assessments, advance care and treatment escalation plans where appropriate) 0.5000 Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion To improve the management of patients with specific long term conditions to ensure patient centred, individualised and integrated care. To ensure patients have a plan which clearly identifies agreed escalation of treatment or management in the community and aims to avoid unnecessary admission. This is a collaborative CQUIN to be developed in conjunction with Yeovil District Hospital NHS Foundation Trust. Patients will have a lead hospital consultant and a care co-ordinator in the community This CQUIN utilises the GP out of Hours Adastra system of ‘Special Patient Notes’ to inform Out of Hours services that patients have a specific escalation plan. Number of patients with an agreed treatment escalation plan in place. Number of patients admitted with the identified long term condition of the cohort considered and where a plan is appropriate. Builds on the recent NHS England guidance “Safe Compassionate Care for Frail Older People using an Integrated Care Pathway”. The complex chronic health problems and functional limitations common in the elderly/long term condition population place them at risk of complicated hospital stays. The preparation of a Management Plan on discharge from acute and community hospitals should improve the effectiveness of discharge planning in identifying clear pathways of clinical management and care at home. Patients with increased functional dependency and problems have a greater likelihood of readmission and emergency department usage therefore there is a need for comprehensive functional assessment as part of discharge planning. Suitable cohorts may include patients with a Respiratory long term condition e.g. COPD, patients assessed via FOPAS and those with mental health diagnoses. The CQUIN will provide valuable information to support the Symphony Project in both pathway design and outcome and measures. Links to inform out of hours providers would be established through the use of the Adastra ‘Special Notes’ system. Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to Commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to Commissioner) Final indicator reporting date Are there rules for any agreed in-year milestones that result in payment Rio Quarterly Provider Quarterly Quarter 2 TBC in quarter 2 Quarter 4 Achievement of 50% in agreed cohorts Commissioners will satisfy themselves that the data submitted accurately reflects the position within the provider organisation. Quarter 4 Quarter 1 – Identify suitable patient cohort, agree template and mechanism for sharing information, pilot development and use Are there any rules for partial achievement of the indicator at the final indicator period/date? with GPs and acute trust partners Quarter 2 - Baseline data to be reported at the end of quarter 2 Quarter 3 – Achievement of 25% Quarter 4 – Achievement of 50% agreed cohort. CCG review of final achievement and acknowledgement of improvement to include partial compliance of 50% year end requirement