0-2

Early Maturity 

The service is in the early stages of being fully developed. Indices who score in this area would likely offer excellent opportunities for improvement and development. 

3-5

Progressing Maturity 

The service is developing and has some good elements and other factors which need to be developed further. There are likely good opportunities here for improvement. 

6-7 

Mature 

This service is highly developed and is likely to be delivering to a high standard but is not yet at the point of benchmarkable. 

8

Benchmarkable Maturity

This service is likely to be at the forefront of its kind. Other organisations could learn from this service. National and regional teams are likely to identify this service for case studies and wider learning. It is likely that staff in this service are at the forefront of improving beyond this matrix. 

1.1

The staffing model consists of a multi-disciplinary team including medical, surgical, nursing, Allied Health Professionals (AHPs), administrative and operational staff. Advanced level practice roles are embedded in the service model (e.g. advanced clinical practitioners, nurse practitioners, clinical nurse specialists, clinical pharmacists).   A senior clinical decision maker is available during peak demand hours for a minimum of 12 hours a day. 

Yes / No 

1.2

A minimum of 33% of non-elective activity is recorded as 0 day length of stay; and the organisation can demonstrate that patients attending SDEC avoided admission due to appropriate case mix selection.

Yes / No 

1.3

Clinicians across the healthcare system have direct access to medical, surgical and frailty SDEC, 12 hours a day 7 days a week matched to peak demand. This is available via clinician-to-clinician referral from ED, 111, 999, & Community/Primary care.

Yes / No 

1.4

The Directory of Service has an accurate profiling of the SDEC service and there is open access to referrals. This supported by minimal exclusion criteria across the ICS footprint, and includes all Type 1, 2 & 3 attendances, including patients deemed awaiting admission.

Yes / No 

1.5

Providers and commissioners regularly (more than 4 times per year) audit activity and patient experience / feedback using recognised methodology to maximise the opportunity to increase same day care provision. Demand and capacity modelling should be reviewed (more than twice per year) to ensure that SDEC footprint is fit for purpose and the ‘fit to sit’ space is maximised to improve patient flow.  

Yes / No 

1.6

All SDEC activity is recorded via Admitted Patient Care records (APC) when activity is transitioned to be recorded on ECDS from July 2023 by July 2024.  

Yes / No 

1.7 

 SDEC has rapid access (equitable to ED) to diagnostics 7 days per week including community diagnostic centres to reduce pressure in acute diagnostic services.   

Yes / No 

1.8

SDEC is not bedded at times of escalation to ensure patient flow is not compromised.  

Yes / No 

2.1

All clinicians have the skills and equipment to undertake a clinical frailty score within 30 minutes of arrival whilst the patient’s ongoing acute problem is being managed.  

Yes / No 

2.2

The acute frailty service supports front door assessment of appropriate patients and a ‘fit to sit’ approach is standard practice for patients where clinically appropriate and internal professional standards support swift onward referral to alternatives to admission where this is clinically appropriate.  

Yes / No 

2.3

Shared care records enable access to clinical frailty information across healthcare settings and a summary of attendance is provided within 24 hours of discharge. 

Yes / No 

2.4

Clinicians across the healthcare system have direct access to frailty services including  

ED / 111 / 999 / Community / Primary Care for a minimum of 12 hours a day, 7 days a week (to include peak demand) via clinical-to-clinical referral.  

Yes / No 

2.5

The staffing model consists of a multi-disciplinary team including medical, nursing, Allied Health Care professionals (ACPs), administrative and operational staff.  

Yes / No 

2.6 

Acute and community frailty services work collaboratively with social care, third sector and voluntary organisation to reduce the risk of admission for social reasons alone. 

Yes / No 

2.7

The hospital uses one Clinical Frailty Scoring (CFS) model and there is evidence this is routinely (all patients >65 years) recorded in ED / SDEC / Acute medical environments.  

Yes / No 

2.8 

For 80% of patients their stay in acute frailty is under 8 hours.  

Yes / No 

3.1

Wards demonstrate a daily board round before 10am with a senior medical decision maker, senior nurse, and members of the wider MDT; and an afternoon huddle to ensure all actions have been completed or are being escalated. 

Yes / No

3.2

The ward has undertaken a self-assessment of their ward rounds processes (using the Royal College of Physicians self-assessment tool).

Yes / No

3.3

The principles of the SAFER patient flow bundle or equivalent are present e.g. do all patients receive a senior review 7 days per week (if required), do all patients have expected dates of discharge (that they are aware of), are there clear plans in medical notes with clinical criteria (functional and physiological) for discharge. 

Yes / No

3.4

Patients are routinely supported to get dressed, get up and mobilise. 

Yes / No

3.5

A post board / ward round huddle to ensure all actions for the day have been allocated and are being recorded. And any / all delays to discharge are escalated in day to maximise the chance the patient can be discharged earlier. 

Yes / No

3.6

The Trust and ICS regularly audit ward processes through peer review, activity, clinical supervision (e.g. grand round / divisional clinical leader reviews) and critical friend visits.  

Yes / No

3.7

Patients and / or next of kin are supported to understand their diagnosis, why they are in hospital, what they are waiting for and when they are likely to go home. 

Yes / No

3.8

A home first culture through observed practice of the board and ward rounds (regular peer review / critical friend review process). 

Yes / No

4.1

Wards undertake a daily morning board round with a senior clinical decision-maker and members of the wider MDT (which may include a doctor) and a post-board and ward round huddle, and an afternoon huddle are used to ensure all actions for the day have been allocated and are being recorded or escalated in day.

Yes / No

4.2

The principles of the SAFER patient flow bundle or equivalent are present: all individuals receive a senior review 7 days per week (if required), everyone has an expected date of discharge (that the patient is aware of), and there are clear plans in notes with clinical criteria (functional and physiological) for discharge.

Yes / No

4.3

Individuals and/or next of kin are supported to understand their diagnosis and their rehabilitation plans, why they are in hospital, when they are likely to go home and what to expect when they go home. Adult social services, housing and voluntary sector partners are aware of care plans and ready to provide a prompt response when people are discharged. 

Yes / No

4.4

Patients are routinely screened for frailty and this score informs rehabilitation plans and discharge decisions. The unit has a proactive approach to preventing deconditioning including asking people to get dressed and mobilised.

Yes / No

4.5

All community beds have completed site level AHP workforce planning and use a daily workforce schedule to enable timely assessment, rehabilitation, and discharge 7 days per week.

Yes / No

4.6

People have therapy-led individual rehabilitation plans which have been created with them and are completed promptly at the point when the person is ready to be discharged home, with access to equipment 7 days a week if required. 

Yes / No

4.7

The multi professional team takes a partnership approach to discharge including early planning and working with local authority partners to provide access to reablement/pathway one services for ongoing recovery support at home. The key elements of the High Impact Change Model are present in the system.

Yes / No

4.8

The Trust and ICS regularly audit ward processes through peer review, clinical supervision (e.g., grand round/divisional clinical leader reviews) and critical friend visits and this also drives improvement in their workforce models including training. The ward has undertaken a self-assessment of their ward round processes (using the Royal College of Physicians self-assessment tool).

Yes / No

6.1

People have an individual rehabilitation plan, when they no longer meet the criteria to reside/on discharge from hospital, with rehabilitation interventions commencing shortly after. 

Yes / No

6.2

Systems know their registered and unregistered therapy workforce numbers and skill mix against their demand for rehabilitation post-acute discharge. 

Yes / No

6.3

All people who require additional care and support following an inpatient stay are referred to a Care Transfer Hub to plan for the provision of their care and support package.

This hub functions as single referral system for assessing and triaging people to appropriate step-down services within one day of no longer meeting the criteria to reside.

There are processes in place to assess people’s ongoing care needs as they come to the end of their intermediate care provision. 

Yes / No

6.4

All local providers of NHS-commissioned community beds submit to the Community Discharge SitRep. 

Daily data for home-based and bed-based intermediate care services (including capacity tracker data) is available and underpins daily demand and capacity operational planning. 

Yes / No

6.5

Data sharing arrangements are in place to enable rehabilitation/recovery plans to be shared by partners providing services, including social care and GP. Rehabilitation/Recovery plans are shared with the individual, their carer(s), advocate(s) and family. 

Yes / No

6.6

There are mechanisms at place and system level to monitor the impact of intermediate care interventions on people’s functional outcomes and their long-term care needs. These inform service reviews and shape future commissioning and planning. 

Yes / No

6.7

Following the Better Care Fund intermediate care capacity and demand planning exercise, joint plans are reviewed and refreshed to guide commissioning decisions and to escalate service or resource gaps. These underpin a trajectory of reducing delayed discharges and improving performance through winter 2023/24 and beyond.

Yes / No

6.8

There are Joint Executive Leadership and system agreements in place across partner organisations, to ensure shared decision making and governance arrangements, including budgetary and national policy alignment. 

Yes / No

7.1

Virtual wards deliver time-limited (up to 14 days) interventions for all ages and monitoring based on clinical need for a secondary care bed. While there may be a wider range of pathways in place, ICS should ensure pathways are developed for both frailty and respiratory conditions with both step up access from community settings and step-down access in place from hospital. 

Yes / No

7.2

Virtual wards are achieving upwards of 80% occupancy in line with the national target and have a strategy for increasing and sustaining referrals over time (including for step up services from community referrals from care homes, ambulance trusts, UCR and primary care).

Yes / No

7.3

ICS should be aiming to offer consistent virtual ward services and pathways across the whole ICS. Virtual wards have clearly defined minimal criteria for admission across the ICS footprint and all virtual ward services are profiled accurately on the Directory of Services (DOS). 

Yes / No

7.4

Virtual wards demonstrate a daily board round with a senior medical decision maker, and members of the wider MDT. Virtual wards have access to specialty advice and guidance as per inpatients to enable timely clinical decision-making. Virtual Wards have capacity to visit patients at home where required during a stay.

Yes / No

7.5

There are clear, formalised pathways developed collaboratively in place to support early recognition of deteriorating symptoms and escalation and out-of-hours support to manage this and maintain patient safety 24 hours a day. This includes patients having clear information on who to contact if their symptoms worsen, including out of hours.

Yes / No

7.6

Virtual wards are enabled by technology and have the capability to monitor patients – as a minimum: 1) patients can measure, and input agreed health data for example vital signs into an app or website (or automatically through wearable tech);  2) these data feed into a digital platform which is reviewed remotely by a clinical team; 3) clinical teams are alerted when a patient moves outside of agreed parameters so appropriate action is taken; and, 4) patients have adequate information to support use of digital technology and to allow informed consent to care.

Yes / No

7.7

Virtual wards have rapid equitable access to diagnostics 7 days per week including point of care testing (POCT) and/or community diagnostic centres to reduce pressure in acute diagnostic services. 

Yes / No

7.8

The virtual ward is aligned/integrated with other services, including urgent community response (UCR), same day emergency care (SDEC), unscheduled care and social care across the system. Virtual Ward objectives are aligned with UEC system goals on flow and demand-capacity.

Yes / No

8.1

Data is used to model the potential scale of UCR service needed to move demand away from acute settings and into the community where safe to do so, based on clinical need within the local population.

Yes / No

8.2

The ICB has a plan in place to:

1.     Expand community capacity to meet the identified demand, ensuring that UCR services have the resources, skills and competencies needed.

2.     Support UCR services to proactively identify caseload from other parts of the system, including but not limited to 999.

Yes / No

8.3

All UCR services within the ICB are linked to the local Single Point of Access / Care Coordination model, and their service model is broad enough to accept all referrals which are deemed to be clinically appropriate for UCR response.

Yes / No

8.4

There is ICB-wide agreement between providers of what constitutes a clinically appropriate referral for UCR, meaning that rejected referrals are minimised. Quarterly audits on rejected referrals and missed opportunities to refer into UCR are carried out and issues are resolved when identified.

Yes / No

8.5

The ICB ensures that UCR services refer into:   

1.     Local virtual ward models to provide community-based step-up care as appropriate.

2.     Planned care services in both primary and community care, mitigating continuous re-referral into UCR for crisis response through addressing ongoing care needs.

Yes / No

8.6

UCR providers are supported to:    

1.     Address local health inequalities priorities and evidence their impact on access and outcomes.

2.     Adopt evidence-based methods of understanding patient / carer experience and act on the results.

Yes / No

8.7

Support is offered to all UCR providers to ensure the accurate recording and timely submission of activity data into CSDS, completely eradicating non-submission.          

Yes / No

8.8

The ICB maximises opportunities for point of care testing and use of technology to support safe patient care.

Yes / No

9.1

Executive buy-in at system level to include key organisational partners across all services that includes ambulance trusts, primary care, acute and community trusts, 111 providers and social care services. 

Yes / No

9.2

SPOA is implemented at scale at place level (or larger) with ICS footprint equity to reduce health inequality for access that is commensurate with the local population requirements and is provided at least 12 hours per day, 7 days a week, 365 days a year.  

Yes / No

9.3

SPOA has one single phone number to enable a simple and efficient referral route that transcends local geographical boundary restrictions. 

Yes / No

9.4

SPOA has real time visibility and proactive management of all relevant patient case loads and lists including ambulance portals.  

Yes / No

9.5

SPOA is staffed with a multi-disciplinary team of senior clinical decision makers both medical and non-medical.

Yes / No

9.6

SPOA supports access to shared care records, direct referrals and booking ability including key services such as SDEC, UCR and virtual wards. 

9.7

SPOA prioritises first contact clinicians including paramedics/ambulance crews to enable access to all non-ED pathways. 

Yes / No

9.8

The system has a learning culture where it continuously reviews the impact and refines it’s SPOA approach to delivery and demonstrates the measurable reduction in the number of steps, clinical assessments, referrals and waits for patients across the system.   

Yes / No

10.1

There is a system led response collaborating across primary, secondary and community services to drive a collective objective to provide timely and appropriate same day urgent care and reduce pressure across the system. 

Yes / No

10.2

There are local referral pathways with agreed and consistent triage models, developed collaboratively with engagement and oversight led by systems. 

Yes / No

10.3

Acute Infection Hubs have been implemented at scale, ideally place level (circa 250,000 population), building on local infrastructure and matching the needs of the population with a focus on areas of higher deprivation where seasonal illnesses are disproportionally prevalent. 

Yes / No

10.4

Provision includes same day urgent access for those with acute episodic needs, prioritising acute respiratory infection but expanding to broader usage as required to maximise utilisation. 

Yes / No

10.5

Hubs are accessible with due consideration to the estate and accessibility of the hubs including public transport routes, parking and reasonable adjustments for people with physical and mental health needs e.g., extended appointments, accessible ramp and development needs. 

Yes / No

10.6

The hub is fully aligned or integrated with other services including 111, virtual wards, same day emergency care (SDEC) and single points of access (SPOA) and be included on the directory of services (DOS) to allow efficient seamless digital patient streaming and shared read and write access to patient records.

Yes / No

10.7

Hubs include data collection to measure impact, outcomes and patient and staff experience to support local evaluation and demonstrate impact on patient safety, quality, effectiveness, service sustainability and to support service improvement. Where collection is manual, efforts should be considered to automate to reduce burden.

Yes / No

10.8

The workforce is carefully planned to meet identified demand and includes integrated pooling of existing staff from across the system with appropriate training to mobilise and operationalise the hubs with additional services and diagnostics are available as required e.g., Point of Care Testing (POCT) to support clinical decision making and avoidable hospital attendance. 

Yes / No