A digital service that allows digital care plans to be created and shared for coordinated care

Having choice and control over the place of death is considered as a quality marker for end of life care. Most people prefer to die at home. However, a great proportion of deaths occur in a hospital rather than in a home setting.

To understand the scale of the problem, in 2008 the palliative care team at The Royal Marsden NHS Foundation Trust agreed to have a single, paper version of the patient’s care record that would be faxed to all urgent care services. Initial data from this process showed that more patients died in their preferred place of death (PPD) with a single care plan compared to baseline average results of 47% achieving their PPD nationally. A decision was then made to digitalise the process.

Situation

In the UK there are 500,000 dying patients each year. Between 2004 to 2006 54% of complaints to the NHS ombudsman concerned end of life care. Of those complaints, 50% related to the poor coordination of care for the dying patient.

Additionally, nationwide 47% of patients die in hospital but when asked, a majority want to die at home. There is not one single shared care plan for dying patients. Therefore, a patient may have multiple care plans at any one time.

There are other forms of electronic palliative care coordination systems (EPaCCS) in use across the UK. However, this service is the only EPaCCS that offers full multidisciplinary access and integration with other systems such as ambulance systems, GP systems and acute hospital systems. This means clinicians located anywhere across a healthcare area can assess, view and edit the same patient’s plan.

Aspiration

In line with the NHS Long Term Plan, the ambition is to deliver more integrated, person-centred care to all those who need it. The Royal Marsden hosts a digital service to record important information about patients who have long-term conditions or are approaching the end of their lives. The digital record can then be shared with the doctors, nurses, ambulance staff and other health professionals who look after them.

Solution and impact

Coordinate My Care (CMC) is a digitalNHS service that allows care plans to be created and shared digitally across London between all healthcare professionals to ensure they are connected 24 hours a day, 7 days a week. The CMC care plan records patient preferences, their key contacts, where they would like to be cared for, what to do if they deteriorate, their Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) status and more. This enables shared decisions made by patients and clinicians in creating a digital CMC plan. Patients can start their own plan online on www.MyCMC.online. The plan is then completed and approved by their clinician by adding the necessary clinical information and medications. The approved CMC plan is then digitally shared in real time with all urgent care providers. Changes cannot be made without the consent of the patient.

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 and deliver patients the care they want. CMC helps to keep patients at home and helps relieve many A&E admissions.

Functionality

Coordinate My Care (CMC) is a NHS clinical service built on a scalable, web-based IT platform delivering digital, multidisciplinary, urgent care planning for end of life care (EOLC) patients and those with long term conditions, across London. It offers robust information, clinical governance, clinical quality, reporting and training.

Plans are made accessible through a web browser, using desktop or mobile devices and patients can view and amend their own plans at any time. A reminder system also encourages GPs and other professionals to review the plans periodically to make sure they still reflect a patient’s wishes.

The CMC plan can 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.

Capabilities

The service is underpinned by an electronic web-based solution and can be accessed by any legitimate provider of care through N3/HSCN, the secure NHS broadband. Patients can start their own plan online and 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 through the 3 IT systems in use in primary care in London.

Scope

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.

CMC launched in Cornwall in March 2021 and over the next few years there are ambitions to expand the service nationally.

Key figures/quotes

As of April 2021, there were more than 134,000 care plans on the CMC system.

The service cites research that shows CMC enables more patients (75%) to die in their preferred place (home, care home or 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. Fewer than 1 in 5 patients with a plan spend their last days in hospital, compared to almost 50% nationally. This, in addition to respecting patient wishes, is saving the NHS an average of £2,100 per patient.

Find out more

Find out more about Coordinate My Care

Key contact

NHS coordinate my care team

coordinatemycare@nhs.net