Creating and sharing care plans across a system

Coordinate My Care (CMC) is a service that allows care plans to be created and shared digitally across London, both in and out-of-hours, to GPs, community nurses, community palliative care teams, hospitals, hospices, social workers, London Ambulance Service, NHS 111 and care homes.

This ensures that all the health and social care professional teams involved in a patient’s care are connected 24/7. The plan covers patient preferences, where they would like to be cared for, their key contacts, what to do if they deteriorate, their Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) status and more.

The aim is to give every patient a say in their own medical care. Shared decisions are made by patients and clinicians in the creation of a digital CMC plan. The plan is then approved by their clinician and digitally shared in real time with all urgent care providers. Nothing can be changed or created in the care plan without the consent of the patient.

Patients can start their own plan online on myCMC, with the healthcare professional completing it by adding the necessary clinical information and medications, some of which – e.g. demographic and GP details – auto-populate.

As soon as the plan is entered into the CMC system, it can be seen by all the healthcare professionals who might be involved in treating the patient, who will all use it to guide the patient’s care.

CMC empowers the multidisciplinary team around the patient to work more effectively together 24/7 and deliver patients the care they want. CMC keeps patients at home and thus relieves many A&E crises.

CMC is underpinned by an electronic web-based solution and can be accessed by any legitimate provider of care through N3, the secure NHS broadband. Patients can view their CMC plans on their own devices. All patients consent to having a CMC record and a record can be created in the best interests of patients who lack capacity. GPs can access the service via the three IT systems in use in primary care in London.

How was it developed?

The original idea came from Professor Julia Riley, consultant in Palliative Medicine at the Royal Marsden and Royal Brompton NHS trusts and the Clinical Lead for Coordinate My Care. The motivation was the uncoordinated care that her terminally ill sister-in-law received and how this led to the patient’s wished not being recognised.

An initial paper-based plan evolved into a digital electronic palliative care plan pilot. Subsequently it came together with another pilot project in different parts of London to become CMC.

Professor Riley says it was a challenge to get all the different organisations across London to agree and then to train some 20,000 professionals in the use of the service. CMC moved to an online portal called myCMC in May 2019, developed so people could start their own plan online.

Who is using it?

Hosted by the Royal Marsden NHS Foundation Trust, CMC is currently available across London, and is funded by the capital’s 32 Clinical Commissioning Groups (CCGs). It is used by GPs, community nurses, community palliative care teams, hospitals, hospices, social workers, London Ambulance Service, NHS 111 and care homes in London.

Over the next few years, there are ambitions to expand the service nationally.

Outcomes

As of May 2019, Coordinate My Care says there were more than 70,000 care plans on the system.

The service cites research that shows CMC enables more patients (75%) to die in their preferred place (home, care home, hospice) and 20% of patients die in hospital, compared to 47% nationally. CMC improves access to care for patients in care homes and patients with non-malignant diseases, such as dementia.

In addition, the service says CMC has already significantly reduced inappropriate and unnecessary hospital admissions. Less than one in five patients with a plan spend their last days in hospital, compared to almost 50% nationally, which, in addition to respecting patient wishes, is saving the NHS an average of £2,100 per patient. The NHS Innovation Accelerator web site has links to evidence.

In a report on the Royal Marsden NHS FT end of life care services, which were rated good, CQC inspectors noted that patients and their relatives were encouraged to share their individual choices and beliefs about their care through the use of the CMC record system so that this information could be shared across teams. The use of the CMC record system was encouraged. This meant there was a record of patient choices and beliefs so that these were widely communicated between the teams. The use of the CMC record system enabled patients and their families to be involved in planning care, particularly around a patient’s choice of where and how they wanted to spend their last weeks and days of life.