Common use of ASSURANCE AND MONITORING Clause in Contracts

ASSURANCE AND MONITORING. The performance of the Community Case Management Scheme will be evaluated against the following key outcome metrics: • Reduction in A&E attendances • Reduction in non elective admission to acute hospitals • Reduction in permanent admissions to residential and nursing care (65+) • Increase in numbers of carers assessed and supported • Increased dementia diagnosis rate • Increase the average score in relation to improving quality of life for people with long term conditions • Identification through risk stratification of at least 2% of the adult practice population who are at high risk of hospital admission A performance dashboard has been developed for the ICCtH Programme/BCF Plan. This will be used by the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive to monitor performance. The Lead partner will report on performance at agreed intervals to the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive. Individual Services within this Scheme will have individual KPIs and performance targets set out in in Services Contracts and service specifications with Providers which will be monitored by the relevant Commissioning Partner as part of normal contract management processes. The Commissioning Partner for the individual Services will report to the Lead Partner for the Scheme on the performance of individual Services. Table 2 Community Case Management Scheme: Services, Commissioning, Contracting, Access Arrangements & Financial Contributions Service provided Description of expenditure from BCF pooled fund Commissioning/ Contract Lead Contract in Place (Provider) Financial contributions £000’s Access/ eligibility NCC CCG NCC Nene CCG Corby CCG C&P CCG Collaborative Care Teams • Core CCTs in all localities providing active case management of risk stratified vulnerable population preventing NEL admissions and facilitating discharges • Dedicated GP/ANP capacity to provide regular clinics, care planning and workforce development in care homes • Targeted interventions for people with COPD & other long term conditions CCGs Yes 757 65 0 Patients identified as high risk by risk stratification tool Risk Stratification • Provision of risk stratification tool to support identification of vulnerable patients within primary care including those at high risk of hospital admission CCGs Yes 47 5 1 GP registered population Carer Support • Integrated carer assessment and support services to support community case management services including: o Young Carers assessment & support o Dementia carers support & training o Carers Hub providing advice & info, training, planned breaks, helpline & website o Emergency Respite Care o Sitting Service Aligned Yes Yes 1417 160 34 Carers eligible under Care Act provisions following carers assessment Joint Information (incl. Telehealth & telecare) • Development of information sharing arrangements based on NHS number and Open API arrangements to meet data sharing national condition of BCF • Provision of telecare equipment to patients and service users to facilitate prevention, early intervention and admission avoidance aims of community case management service. Aligned No No 212 23 5 Patients/ service users in receipt of community case management service and /or meeting NCC eligibility criteria

ASSURANCE AND MONITORING. The performance of the Community Case Management Crisis Intervention and Admission Avoidance Scheme will be evaluated against the following key outcome metrics: • o Reduction in A&E attendances • o Reduction in non elective admission to acute hospitals • o Reduction in permanent admissions to residential and nursing care (65+) • Increase in the numbers of carers people 75+ conveyed to hospital where there has been a Fall without obvious injury which requires hospital care. o Individuals with mental health needs who are assessed as urgent patients will be seen by the APL service within 1 hour and supported • Increased for non-urgent patients within 4 hours. o Individuals with mental health needs referred by wards will be seen within 24 hours by APL service o Reduced length of stay for patients with mental health needs o Increase dementia diagnosis rate • Increase the average score in relation to improving quality of life for people with long term conditions • Identification through risk stratification of at least 2% of the adult practice population who are at high risk of hospital admission o Improved patient experience A performance dashboard has been developed for the ICCtH Programme/BCF Plan. This will be used by the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive to monitor performance. The Lead partner will report on performance at agreed intervals to the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive. Individual Services within this Scheme will have individual KPIs and performance targets set out in in Services Contracts and service specifications with Providers which will be monitored by the relevant Commissioning Partner as part of normal contract management processes. The Commissioning Partner for the individual Services will report to the Lead Partner for the Scheme on the performance of individual Services. Table 2 Community Case Management Crisis Intervention and Admission Avoidance Scheme: Services, Commissioning, Contracting, Access Arrangements & Financial Contributions Service provided Description of expenditure from BCF pooled fund Commissioning/ Contract Lead Contract in Place (Provider) Financial contributions £000’s Access/ eligibility NCC CCG NCC Nene CCG Corby CCG C&P CCG Collaborative Care Teams Acute Psychiatric Liaison Service • Core CCTs Multidisciplinary Psychiatric Liaison Service at Northampton General Hospital and Kettering General Hospital- providing services in all localities providing active case management of risk stratified vulnerable population preventing NEL admissions A&E,wards & outpatients • Service comprises social care elements provided by NCC and facilitating discharges health elements provided by Northamptonshire Healthcare Foundation Trust • Dedicated GP/ANP capacity to provide regular clinics, care planning and workforce development in care homes • Targeted interventions for people with COPD & other long term conditions Service operates 7 days per week CCGs Yes 757 65 0 (NCC) Yes (NHFT) 212 23 5 Patients identified as high risk by risk stratification tool Risk Stratification aged 18+ presenting with MH needs (including dementia) in A&E or wards Crisis Response Falls Service • Provision Falls Ambulance x 2 available 24/7 • Immediate access to short term social care support from Crisis Response Team • Access to equipment/telecare Aligned Yes (OSC) Yes (EMAS) 1404 155 34 Patients aged 75+ who have had a fall without overt injury OPMH/ Dementia Intermediate Care Service Dedicated dementia reablement pathway in south of risk stratification tool to support identification of vulnerable patients within primary county providing: • 8 specialist dementia care including those at high risk of hospital admission CCGs Yes 47 5 1 residential beds Southfield House • GP registered population Carer Support Cover • Integrated carer assessment Community Reablement Team comprising social care and support services to support community case management services including: o Young Carers assessment & support o Dementia carers support & training o Carers Hub providing advice & info, training, planned breaks, helpline & website o Emergency Respite Care o Sitting Service health professionals • Aligned Yes Yes 1417 160 34 Carers 361 40 9 Patients with dementia in south of county eligible under Care Act provisions following carers assessment Joint Information (incl. Telehealth & telecare) • Development of information sharing arrangements based on NHS number for intermediate care and Open API arrangements to meet data sharing national condition of BCF • Provision of telecare equipment to patients and service users to facilitate prevention, early intervention and admission avoidance aims of community case management service. Aligned No No 212 23 5 Patients/ service users in receipt of community case management service and /or meeting NCC eligibility criteriacriteria for reablement (OSC) (NHFT & GP Practice)

ASSURANCE AND MONITORING. The performance of the Community Case Management ICCtH / BCF Enabler Scheme will be evaluated against in the following key outcome metrics: • Reduction in A&E attendances • Reduction in non elective admission to acute hospitals • Reduction in permanent admissions to residential and nursing care (65+) • Increase in numbers of carers assessed and supported • Increased dementia diagnosis rate • Increase the average score in relation to improving quality of life for people with long term conditions • Identification through risk stratification of at least 2% light of the adult practice population who are at high risk overall performance of hospital admission the ICCtH / BCF programme. A performance dashboard has been developed for the ICCtH Programme/BCF Plan. This will be used by the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive to monitor performance. The Lead partner will report on performance at agreed intervals to the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive. Individual Services within this Scheme will have individual KPIs and performance targets set out in in Services Contracts and service specifications with Providers which will be monitored by the relevant Commissioning Partner as part of normal contract management processes. The Commissioning Partner for the individual Services will report to the Lead Partner for the Scheme on the performance of individual Services. Table 2 Community Case Management ICCtH/BCF Enabler Scheme: Services, Commissioning, Contracting, Access Arrangements & Financial Contributions Service provided Description of expenditure from BCF pooled fund Commissioning/ Contract Lead Contract in Place (Provider) Financial contributions £000’s Access/ eligibility NCC CCG NCC Nene CCG Corby CCG C&P CCG Collaborative Care Teams Disabilities Facilities Grant • Core CCTs in all localities providing active case management County Council grant to Northamptonshire District and Borough Councils for provision of risk stratified vulnerable population preventing NEL admissions and facilitating discharges • Dedicated GP/ANP capacity home adaptations to provide regular clinics, care planning and workforce development in care homes • Targeted interventions for people with COPD disabilities • District & Borough Councils supplement NCC allocation with locally determined DFG budget • NCC can provide additional funding where benefits to the Community and NCC can be proved See note 1 See note 1 1957 People with disabilities (adults & children) meeting District & Borough Councils (x7) eligibility criteria for a DFG. Community OT service assesses against relevant local authority eligibility criteria. Eligibility subject to means test for adults Social Care Capital Grant • Capital funding to support core purposes of adult social care. 566k of the capital funding has been earmarked for the Care Act(including IT) associated with transition to the capped cost system, which will be implemented in April 2016 NCC N/A N/A 1513 . Same governance to spending to be applied as per the other long term conditions CCGs Yes 757 65 0 Patients identified as high risk NCC contributions to the BCF. Approval to spending plans to be obtained within NCC and reported to the HSC Executive Care Act spending decisions to be approved by risk stratification tool Risk Stratification the Care Act Programme Board Joint Commissioning Capacity • Provision of risk stratification tool additional commissioning capacity to support identification ICCth/BCF Integration (interim support to Intermediate Care strategy service specification) • Joint Dementia Commissioner post Xxxxxxx N/A N/A 213 23 5 Application of vulnerable patients within primary care including those at high risk of hospital admission CCGs Yes 47 5 1 GP registered population Carer Support • Integrated carer assessment and support services funding to be agreed via HSC Executive to support community case management services including: o Young Carers assessment & ICCtH/BCF Plans Care Bill Implementation • Revenue funding to support o Dementia carers support & training o Carers Hub providing advice & info, training, planned breaks, helpline & website o Emergency Respite all aspects of Care o Sitting Service Aligned Yes Yes 1417 160 34 Carers eligible under Bill implementation by NCC adult social care during 2015/16. NCC N/A N/A 1385 161 Spending decisions to be approved by the Care Act provisions following carers assessment Joint Information (incl. Telehealth & telecare) • Development of information sharing arrangements based on NHS number and Open API arrangements to meet data sharing national condition of BCF • Provision of telecare equipment to patients and service users to facilitate prevention, early intervention and admission avoidance aims of community case management service. Aligned No No 212 23 5 Patients/ service users in receipt of community case management service and /or meeting NCC eligibility criteriaProgramme Board

ASSURANCE AND MONITORING. The performance of the Community Case Management Discharge & Intermediate Care Scheme will be evaluated against the following key outcome metrics: • Reduction in A&E attendances • o Reduction in non elective admission to acute hospitals • o Reduction in delayed transfer of care o Reduction in system waits in all elements of intermediate care pathway (LOS is consistent with relevant service standard) o Reductions in permanent admissions of patients 65 plus to residential and nursing home care (65+) • o Improved patient experience o Increase in dementia diagnosis o Increase numbers of carers assessed and supported • Increased dementia diagnosis rate • Increase the average score in relation to improving quality of life for people with long term conditions • Identification through risk stratification of patients 65 plus still at least 2% of the adult practice population who are at high risk of home 91 days after re-ablement intervention following discharge from acute hospital admission A performance dashboard has been developed for the ICCtH Programme/BCF Plan. This will be used by the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive to monitor performance. The Lead partner will report on performance at agreed intervals to the ICCtH Programme Board and the Health & Social Care Joint Commissioning Executive. Individual Services within this Scheme will have individual KPIs and performance targets set out in in Services Contracts service contracts and service specifications with Providers which will be monitored by the relevant Commissioning Lead Partner as part of normal contract management processes. The Commissioning Partner for the individual Services will report to the Lead Partner Partners for the Scheme on the performance of individual Services. Table 2 Community Case Management Discharge & Intermediate Care Scheme: Services, Commissioning, Contracting, Access Arrangements & Financial Contributions Service provided Description of expenditure from BCF pooled fund Commissioning/ Contract Lead Contract in Place (Provider) Financial contributions £000’s Access/ eligibility NCC CCG NCC Nene CCG Corby CCG C&P CCG Collaborative Integrated Discharge Team • Multi disciplinary staff teams (North and South) • Accommodation/Office and IT equipment Aligned NCC TBC Yes (NHFT) 0.00 998 110 24 Hospital inpatients requiring community care or CHC Intermediate Care Teams Team • Core CCTs Medical and Nursing Staff • Transport • Medical and Nursing supplies Nene CCG Yes (NHFT) 0.00 5463 632 128 Patients in community or awaiting discharge from hospital requiring hospital at home service Short term Domiciliary Care Dedicated short term domiciliary care to support IDT and discharge process. Reduces DTOCs & Excess Bed day costs. NCC Yes (Dom Care Agencies) 0.00 779 86 19 Service users meeting NCC eligibility criteria Discharge to Assess Dedicated short term service to facilitate discharge of potential CHC patients until assessment completed. Supports IDT process & reduces DTOCs. Nene CCG Yes (Dom Care Agencie s) 0.00 427 47 10 Hospital I/Ps potentially eligible for CHC Stepping Stones 9 specialist accommodation units to facilitate discharge of patients requiring adaptations to own homes or alternative accommodation reducing DTOCs & excess bed days NCC Yes (3rd sector provider) 0.00 132 15 3 Hospital I/Ps requiring adapted housing to facilitate discharge START Social care re-ablement service providing up to 6 weeks re-ablement for patients being discharged and patients in NCC Yes 0.00 4147 457 100 Service users meeting NCC eligibility criteria for community (Olympus Care) reablement service Community Hospitals 87 community hospital beds in Corby, Wellingborough and Daventry providing a range of non acute inpatient services including medical rehabilitation, palliative care and step up. Nene CCG Yes (NHFT) 0.00 5939 689 0.00 Patients in community or awaiting discharge from hospital who meet NHFT eligibility criteria for admission to community hospital Specialist Care Centres Three 48 bed short term residential units in Northampton, Corby and Rushden providing reablement and respite services for people with predominantly social care needs with 10 designated nursing beds in each centre. NCC Yes (Xxxx Homes) 8500 1555 159 14 Patients in community or awaiting discharge from hospital who meet NCC eligibility criteria for admission to reablement beds Rehabilitation Beds Specialist inpatient and rehabilitation unit for patients with brain injury and stroke Nene CCG Yes (NHFT) 0.00 2101 243 0.00 Patients awaiting discharge from hospital who meet NHFT eligibility criteria for admission to specialist medical rehabilitation service Community Nursing Provision of community nursing service in all localities providing active case management of risk stratified vulnerable population preventing NEL admissions and facilitating discharges • Dedicated GP/ANP capacity to provide regular clinics, care planning and workforce development in care homes • Targeted interventions for people with COPD & other long term conditions CCGs Yes 757 65 0 Patients identified as high risk by risk stratification tool Risk Stratification • Provision of risk stratification tool to support identification of vulnerable patients within supporting primary care including those at high risk Nene CCG Yes (NHFT) 0.00 11028 1280 Community Equipment The purchasing, delivering, fitting, collecting and recycling of hospital admission CCGs community equipment. NCC Yes 47 5 1 GP registered population Carer Support • Integrated carer (Millbrook) 2369 1039 121 12 Equipment will be supplied to adults and children following assessment and support services to support community case management services including: o Young Carers assessment & support o Dementia carers support & training o Carers Hub providing advice & info, training, planned breaks, helpline & website o Emergency Respite Care o Sitting Service Aligned Yes Yes 1417 160 34 Carers eligible under Care Act provisions following carers assessment Joint Information (incl. Telehealth & telecare) • Development of information sharing arrangements based on NHS number prescription by authorised health and Open API arrangements to meet data sharing national condition of BCF • Provision of telecare equipment to patients and service users to facilitate prevention, early intervention and admission avoidance aims of community case management service. Aligned No No 212 23 5 Patients/ service users in receipt of community case management service and /or meeting NCC eligibility criteriasocial care prescribers.