Ensuring that patient and carer’s wishes and preferences are at the core of decisions made in an urgent care situation with clinician-approved personalised care plans. Patients with Coordinate My Care (CMC) plans die less frequently in hospitals. On average, approximately 50% fewer patients who have a CMC plan who die, will die in hospital.
What Coordinate My Care (CMC) can do for...
Confidence that their care wishes are understood, documented and available to everyone who will be responsible for their care.
Ensuring clinical safety is at the heart of the service with the ability for the patient’s most up-to-date information to be available to health and social care professionals when it is needed. This reduces unwanted hospital admissions and can realise savings for the NHS as a whole.
Urgent care practitioners
Patient-created, and clinician-completed plans are standardised and easily accessible. This means patients are at the centre of their care. CMC supports the delivery of the NHS 2022 planning guidance priorities:
- Improving the responsiveness of urgent and emergency care and community care capacity
- Using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities
- Achieving a core level of digitisation in every service across systems
What the service does
Ensuring critical information is available to the right people
CMC ensures that vital information about individual patients is available in the right place at the right time to enable the best care to be delivered 24/7, in line with patients' wishes. It offers access to the enhanced Urgent Care Service within a Shared Care Record.
Transforming the clinical service
CMC delivers a redesigned way of working across the whole Integrated Care System, using new pathways, and coordinating care across all health and social care services.
At the heart of the CMC service, is a personalised care plan co-created by the patient and their doctor or nurse.
Transforming these pathways is about more than simply delivering a digital solution. The key to implementation is getting people to use it effectively and efficiently. CMC provides:
- Teaching and training for clinical and administration staff on how to conduct the most sensitive conversations with patients and their families and how to create and use high-quality urgent care plans.
- Real-time clinical audit reporting to clinical teams about the quality of the care plans they create.
- Feedback on the outcomes for their patients as a result of their plans.
- Systematic identification of vulnerable patients, benchmarking and guidance on reliable and sustainable urgent care planning at a local level. This reduces inequality as every vulnerable patient is prospectively identified.
- Plans can be created locally by clinicians or centrally by SCW’s clinicians.
CMC works as an enhanced service within any Shared Care Record, supporting patients who require out-of-hours support such as those with chronic long-term conditions, mental health needs and end-of-life care.
How CMC works
There are two aspects to the effective delivery of the Coordinate My Care service:
Coordinate My Care
The urgent care plan works with any shared care record. CMC accesses the data and collects the dataset required for the CMC template each day. The data is used to feedback to clinicians about patient outcomes, monitor the quality of plans, review clinical incidents and create monthly commissioner dashboards to quantify the improved patient outcomes.
The CMC team works with local stakeholders to initiate and manage the project to deliver the service. Guidance is provided for the implementation and subsequent maintenance of the service.
Programme support includes:
- Population analytics to identify appropriate cohorts of patients (e.g end of life, complex high-intensity users)
- A communication and engagement strategy that is bespoke for individual areas
- A training strategy for creators of plans (GPs, nurses, consultants, AHPs, hospice staff and social workers)
- A training strategy for viewers of plans (111, 999, ambulance services, A&E, urgent care centres, out-of-hours GPs, pharmacists)
- Governance strategy to monitor the quality of the care plans, clinical incidents and PROMs (patient-reported outcome measures)
- Audit and research service to drive continuous improvement
- A 24/7 helpdesk service
How CMC works
- Patients are at the centre of their plans. Their wishes and preferences are respected even when they are too ill to communicate them.
- Most patients would prefer to die at home. Currently, in England, 43% die in hospitals. This number is reduced to 21% who die in hospitals where patients have a CMC plan.
- Patient care is better coordinated and seamless at times of distress when their GP practice is closed.
- Families know that the care delivered has been chosen by the patient.
- Removes duplication of care planning. The responsibility of creating Advanced Care Plans (ACPs) for patients is shared.
- Services are provided for patients in a joined-up way 24/7.
- Avoidance of unnecessary hospital admissions.
- Saving £2,100 per patient who dies with a CMC plan in place.
- Potential saving per million population £27million/year.
- Reduced pressures on urgent care services as patients have a care plan that can be followed.
What the patients who use it say
My CMC plan has it all, my care preferences, my medication, my nearest and dearest. It is so reassuring to know that if I am unable to tell healthcare professionals myself, it is all there for them to read 24/7.
When creating My CMC care plan together with my son who has mental health illness, for the first time we thought about the triggers that lead to crises. We documented them in the logical way and that helped to start recognising crises and calling for help much earlier. It is very reassuring to know that paramedics will access his plan on the way and arrive prepared to deal with the crisis. If conveyance is needed, my son will be transferred to the ward indicated on the care plan, where everyone knows him.
What the paramedics who use it say
CMC has been a paradigm shift for our staff and has changed the way we treat patients for the better...