Information summary - Data and measurement

All Hospital at Home (H@H) services in Scotland operate in a unique way, while following the key elements laid out in the Guiding Principles document.  

For a better understanding of what this means for the different services, we have pulled together the relevant information about data and measurement. The data are taken from the information sheets that were provided by the services, originally in October 2022.  

The information in this document was accurate at the time of publication but as services evolve, the information will change. This document will be reviewed and updated annually.  
 

What are you measuring, if anything, in addition to the data submitted to the ihub? 

 
Aberdeen City 

• Median length of stay 
• Readmission rates 
• Referrals: 
  • Accepted and declined 
  • Managed 
  • Why they were declined 
• Outcomes of care (where they have gone to)
• Where patients are admitted from, and 
• Where they are discharged to. 
  
  

Dundee City 

Previously recorded reasons for admission, referrals to Allied Health Professionals (AHP) and referral for investigation. 
We are now measuring Clinical Frailty Scale (CFS) in patients upon admission to prioritise input from MDT. 
 

Glasgow City 

Full evaluation framework with emerging Key Performance Indicators (KPIs). Details can be shared along with the first main evaluation report once it has been signed off. 

Fife 

• Monthly H@H Dashboard produced that includes the following data: 
  • Total No. Of Referrals Received Since Implementation (per Team and Fife wide) 
  • Average No. Of Referrals Accepted Per Team Per Week 
  • % Split of GP/step-down Referrals Accepted (split Mon-Fri and weekend) 
  • Monthly breakdown (each H@H Team & Fife wide) of: 
    • Overall Total No. Of referrals received (split Mon-Fri and weekend) 
    • No. of GP Referrals accepted (split Mon-Fri and weekend) 
    • No. of step-down referrals accepted (split Mon-Fri and weekend) 
    • No. of Clinic referrals accepted (split Mon-Fri and weekend) 
    • Total No. of referrals accepted (split Mon-Fri and weekend) 
  • Total No. of occasions reached maximum capacity (each team & Fife wide) 
  • Reached maximum capacity information split into days per week/time of day/if reached maximum capacity was for step-down referrals only, GP referrals only, or all referrals  
  • Monthly caseloads data  
• Use a weekly Blog report. 
• MORSE reports  
• Quality information, for example, blood glucose monitoring 
• Following on from the measuring capacity work we are using the Opal tool as this is aligned to what the organisation is using. Currently testing and adapting, using the information already gathered but reporting it to the organisation. 
   

Forth Valley 

We set some standards for the service, for example, the first visit should be done within two hours and when a consultant review should be carried out. 

We measure: 

• Time to first visit, and 
• Times for senior review.  

We are currently looking closer at a subset of patient groups (such as a heart failure group). The aim is that we will understand the groups and pathways better. We are also looking to link in with community respiratory. 

Moray 

• We are collecting data on a spreadsheet, and are currently receiving input from a public health analyst to formalise our data.  
• The data being collected is activity data, not outcome data yet. We are still to decide on what outcomes to include. 
  
  

Lanarkshire 

We record referral source, locality, clinical detail and whether or not the patient was seen by their GP prior to H@H referral. We are going to begin recording which interventions patients have had while under H@H care and which onward referrals were actioned.  

Perth and Kinross 

• Data collection is in early stages. Initially, H@H service will use standard data collection which is in practice in the Advanced Nurse Practitioner (ANP) Service, focusing on key impact areas such as length of stay, hospital admission and readmission and disease presentations leading to admission to H@H. 
• The Healthcare Improvement Scotland template will be used once fully operational. 
  
  

Lothian 

Midlothian 

We keep a spread sheet (Excel) with patient data (age, GP practice, referring condition), the source of referral, discharge date, length of stay and acuity score.  

We record staffing levels and occupied bed numbers.  

Edinburgh 

A basic data set has been agreed and is discussed at monthly senior staff meetings, local QI meetings and oversight team meetings. 

West Lothian 

List of discharges with details of admission date and discharge, diagnosis and onward referrals. 

Daily list of caseload and staffing. 

East Lothian 

We monitor referral data and plot against agreed quality of care metrics such as average length of stay and seven-day re-admission percentage. We look at patients who stay for longer than seven days to review decision making and ensure their inpatient stay was effective and efficient. We are reviewing our 28-day re-admission rates to understand if recent service changes have had an overall beneficial effect to patient care and journey. 

Western Isles 

• Length of inpatient hospital stay then length of H@H stay. 
• Conditions that patients have arrived with, and 
• Referring consultant. 

 

What system are you using to collect your data (for example, manual data collection, pulled from existing electronic systems)? 

Aberdeen City 
Depending on the request: 

• Manual  
• Spreadsheet 
• Morse 
• Trakcare 
• Boxi, or 
• Illuminate 
  
  

Dundee City

A Combination of manual data collection, EMIS and Trakcare. 

Glasgow City

• Trackcare for clinical information.  
• Pharmacy system 
• Central spreadsheet for a range of information to inform the evaluation framework, and 
• Development of a dashboard for operational and reporting in progress. 
  
  

Fife 

The data that is report to HIS monthly is from reports produced via eHealth. 

The Acuity & Dependency and the CRAGS data is all manual collation  

The monthly H@H dashboard that is produced is data pulled from a variety of spreadsheets and blogs, but this is all manual, as is the dashboard. 

Forth Valley 

We carry out manual data collection for standards. We use Trakcare to pull a certain amount of data.  In addition, we record: 

• Daily capacity 
• Referrals 
• Referrals declined, and 
• Reasons for declining 

These data are collected via admin support and coordinator.

Moray 

• Manual data collection (do not have access to the same IT systems in primary care, not currently interlinked). 
• Existing electronic systems, and   
• Working with LIST to develop data collection method.
   

Lanarkshire  

We also request reports to be pulled from Trakcare on Hospital admission and other information. 

Perth and Kinross 

Spreadsheet based patient database at the moment managed manually. 

Lothian 

• Manual input into Excel, and 
• BOXI reports pulled from TRAK. 
  
  

Western Isles 

• Manually collected. 
• Health Intelligence Team collect length of stay, consultant and the reason that a patient was admitted to H@H. 

 

Do you have data analyst support in your service? 

Aberdeen City 

No  

Dundee City 

There is limited input available via the NHS Tayside Business Unit. 

Glasgow City 

Yes 

Fife 

Data collection and analysis is a significant part of the role of our community services development officer.  

Our community service development officer has formed strong links with information analysts. The information analysts have supported H@H in producing either one off reports and/or implementing new automated reports as required.  

Using MORSE to share clinical records and get a report from data analysts monthly. 

Forth Valley 

Not really any more but can contact them if needed. 

Moray

Yes 

Lanarkshire 

Project Manager currently works with the data. 

Perth and Kinross 

Yes 

Lothian 

The H@H Teams have access to the Unscheduled Care Analytical Team. 

Western Isles 

Health Intelligence Team. 

 

How do you use the data you collect (i.e. to understand the system, to plan, to improve)? 

 

Aberdeen City 

• Expansion project, and  
• Any application bids for funding 

 
Dundee City 

We use the CFS to ensure we were completing anticipatory care plans and having discussions around ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) forms. 
A planned date discharge is set for every patient on the caseload to focus on shared care decision making and to involve appropriate services at an early stage. 
The acuity tool which has been modified for our team will hopefully inform us where there is a need, if the right person is looking after the patient and how we best use our resources. 

Glasgow City 

Key to evaluation framework to inform the pathway, clinical and other improvement opportunities and to inform the potential for scale up within the existing test of change and subsequently as a system wide service. 

Forth Valley 

We use additional data to improve the service, and create standards to aim towards. 

Moray  

This is currently under review. 

Lanarkshire 

We use the data we collect to monitor the performance of our service and to inform decisions on change and development. We also use the data to plan our expansion into other areas. 

Perth and Kinross 

Initial stages of data collection at the moment. Feedback has been used to adapt the approach of the service. Data will be used to shape the future service and understand needs and requirements of the service. 

Lothian 

• We have used data to demonstrate capacity demands, where referrals come from and to target information about our service to low referrers.  
• To conduct audit.  
• To evidence need for staffing, and 
• Metrics are shared at team meetings to encourage good practice and have open dialogue around service pressures. 
  
  

Western Isles 

• We haven’t done much with it at the moment but likely to use during expansion. 
• It has been used to highlight the work that the team are doing.