Created by NHS Clinicians for NHS patients

Coordinate My Care (CMC) – Personalised,

digital urgent care records

Manchester

23rd February 2016, London

Prof Julia Riley - CMC Clinical Lead

What is the problem……my story

• Lack of coordination…..

• COST – patient, cost to NHS

April

November

2

• Patient centric care plans

• Medical

• Nursing

• Social

• Financial

• Spiritual

• Cultural

• Multiple faxing

• Not contemporaneous

2007

Introduction of ‘Hospital2Home’

3

• EoLC strategy

• DH Pilots

• London x 2

Hospital2Home development

Sutton and Merton

Camden and Islington

2008

4

• Coordinate My Care

• Pan London

• EoLC

• Connect to London Ambulance Service

• NHS 111

• GP OOH

2010

Coordinate My Care – Pan London

5

With regard to patient data sharing, a YouGov survey found that:

30% of respondents were “shocked”

40% “annoyed

61% “worried” that their GP records are not available to A&E

8% were “not bothered”

4% thought that was how it should be

http://d25d2506sfb94s.cloudfront.net/cumulus_uploads/document/c6fjeoscct/YG-Archive-140808-A&E.pdf

What the patients say….

What the urgent care services say…

One standard up-to-date multi-disciplinary digital urgent care plan per

patient

One…

‘one version’ of the truth

Up-to-date…

do not want to worry about out-

of-date information

Standard…

want to see consistent structured

identical plans

Multi-disciplinary…

want to see information from a patient’s whole

care team

Digital…

want quick and easy access to

the plan

1 2 3 4 5

One standard urgent care plan per patient

Non-Urgent

Clinicians have time & patient knowledge to interpret/benefit from a collection of diverse and potentially contradictory information

Urgent

Clinicians require a standardised, high quality action plan without superfluous or duplicated

NHS Pathways – 111, 999, A&Es, UCCs etc.

Call transferred to Clinical Hub 111 Clinician accesses the CMC care plan

Paramedic, district

nurse, ambulance,

or appropriate

HCP dispatched

Public call to

LAS

1

NHS Pathways –

disposition as per

DOS

Select appropriate

disposition e.g.

district nursingAmbulance

dispatched

NON URGENT

Symptom NOT on

the CMC care plan

e.g. flu

NON URGENT

Symptom pertains to

CMC care plan e.g.

pain control

URGENT

Symptom not on

CMC care plan e.g.

fracture, or severe

distress e.g. bleed

A system ‘flag’ indicates the

existence of a CMC care plan

Public call to

NHS 111

2

A system ‘flag’ indicates the

existence of a CMC care plan

Current CMC offering

Coordinate My Care

Nursing Homes

Care Homes

Hospices

Acutes

GPs

MDT Urgent Care Plans

LAS OOH 111 A&E

In-context linksAllows users to access CMC from within their own systems e.g. EMIS Auto-flagging

Users are notified of existing care plans within their own

systems

CMC User-InterfaceIntuitive & user friendly

system

2. Information and clinical governance

Signed Information Sharing

Agreement

Manager has signed authorisation and

I am an authorised user

Employing Organisation

I have attended training

I have signed and returned CMC Acceptable Use

Policy

Individual

CMC access is granted

PLUS

CONSENT, reporting, auditing, clinical incident

investigations

Signed Information Sharing

Agreement

Manager has signed authorisation and

I am an authorised user

Employing Organisation

Signed Information Sharing

Agreement

Manager has signed authorisation and

I am an authorised user

Employing Organisation

I have attended training

I have signed and returned CMC Acceptable Use

Policy

Individual

I have attended training

I have signed and returned CMC Acceptable Use

Policy

Individual

CMC access is granted CMC access is granted

PLUSPLUS

CONSENT, reporting, auditing, clinical incident

investigations

12

2015

Simple navigation to key medical information

CPR information

Key medication information

17

CMC OUTCOME DATA

19

CMC Activity and Outcomes

26,998 patients have a CMC personalised care plan

11,432 deaths –only 17% died in hospital. Nationally, 54% die in

hospital

6,978 expressed a preference 78.2% achieved it

Data: to 19 February 201620

Source: Deloitte 2014 NHS 111 Learning Review

NHS 111 Learning programme

showed patients with a CMC plan

are 50% less likely to need an

ambulance and 80% less likely to

be referred to an ED

Ambulance & ED referrals

21

4. PATIENTS' PREFERRED PLACES OF CARE AND DEATH

FOR NHS CROYDON CCG AREA

Commentary

Overall 80% of NHS CROYDON CCG area CMC patients have died in their preferred place. Where NHS

CROYDON CCG area patients have a CMC record, 14% die in hospital. However, nationally, 54% die in

hospital*.

*National End of Life Care Intelligence Network, NEOLCIN, 2008-10

Recorded Deaths of CMC Patients in NHS CROYDON CCG Area 1575

Of these, Place of Death recorded 1396

Of these, patients expressing a PPD 1161

Met PPD 1 865 74.5%

Met PPD 2 61 5.3%

Met PPD 1 or met PPD 2 926 79.8%

Not met PPD 235 20.2%

6. PROFESSIONAL GROUPS ADDING TO CMC FOR NHS CROYDON CCG AREA

CMC A SERVICE NOT AN IT SYSTEM

28

A service rather than an IT system

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

Training

• Cascade training• E Learning• Webex

Reporting

• Organisation level e.g. GP practice to CCG

• Granular activity monitoring – access and edits

• Range of KPIs – PPD

Governance

• Information

• Clinical

-Incident reporting

R&D

• Stakeholders, audit, research

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

23237 CMC care plans have been created since August 2010

78% of CMC patients have died in their preferred place ¹

¹ 1 Apr 2015 to 31 Aug 2015

² NEOLCIN, 2008-2010

3. Recorded diagnosis 1

1. Access to CMC by urgent care providers 1

4. Preferred place of death 1

2. Actual place of death 1,2

Where patients had a CMC plan, 85% died outside of hospital,

15% died in hospital ¹

71.3%

6.9%

21.7%Met PPD1

Met PPD2

Not met PPD50%

17%

13%

6%

5%4%

3% 2%

Cancer

Dementia

Other

Unclassified

Cardiac

Neurological

COPD

Renal

1251

636

167 461% 31% 8% 0%

111 Provider Ambulance Service

Out of Hours GP Provider

Accident & Emergency

Total views 2058

54%

20%18%

5%3%

15%

36%

30%

18%

1%

Hospital Home Care Home Hospice Other

England ² CMC ¹

A service rather than an IT system

CULTURE CHANGE

• New process – planned care not reactive care

•Patient centric model

•Having difficult conversations

•Create a joint urgent care plan

•Trusting and sharing one urgent care plan created by multiple

professionals, in real time

• Working as a virtual multidisciplinary team

• Audited outcomes

SYSTEM CHANGE

CMC DEVELOPMENT ROADMAP

31

CMC roadmap

Phase 1

24th November ‘15

Phase 2

March ‘16

Phase 3

Summer ’16

Intuitive & user-

friendly

Patient Portal

Read-only access

Patient Portal

Full access

Interoperability

EMIS In-Context

Mobile devices

Interoperability

EMIS In-Context

Mobile devices

TPP In-Context

Vision In-Context

Adastra In-ContextLonger term

Full interoperability with key GP, Acute, Community & Urgent Care systems.

Patient portal

Organ donation

Advance decision

to refuse treatment

My will

DNAR/CPR

My goals

My spiritual &

cultural beliefs

*

**

*

*

*

Dvd explanations

Xxxx

Xxxx

xxxx

Xxx

Xxx

xxx

If you would like a shared URGENT CARE PLAN please contact doctor or nurse

TT

My NHS number

My diagnosisFit and well

Chronic illness

Terminally ill

My support, family,

carers, loved ones

CONTACT DETAILS

My likes and

dislikes

Funeral

arrangements

Outcomes

Patient & ClinicianPatient

Coordinate My Care

CMC care

record

CMC UrgentCare Plan

CMC is hosted by The Royal Marsden NHS Foundation Trust

‘PLANNING URGENT CARE DURING NON URGENT TIMES’

www.coordinatemycare.co.uk