CMC is hosted by The Royal Marsden NHS Foundation Trust

Joined up Health and Care

Dr Julia Riley - CMC Clinical Lead

29 June 2015

Created by NHS Clinicians for NHS patients

My story

2

November

April

• Lack of coordination…..

CMC DEVELOPMENT

3

• Patient centric care plans

• Medical

• Nursing

• Social

• Financial

• Spiritual

• Cultural

• Multiple faxing

• Not contemporaneous

2007

Introduction of ‘Hospital2Home’

4

Hospital2Home development.....datasets

2008

5

• EoLC strategy

• DH Pilots

• London x 2

Hospital2Home development.....datasets

Sutton and Merton

Camden and Islington

2008

6

• Coordinate My Care

• Pan London

• EoLC

• Connect to London Ambulance Service

• NHS 111

• GP OOH

2010

Coordinate My Care – Pan London

7

Coordinate My Care – Pan London

• Built on Social Services platform

• Robust

• No clinical incidents related to IT

HOWEVER

• ‘Cluncky’

• Lack of interoperability

• Not intuitive

2010

8

URGENTSymptom NOT on

CMC care plan

999

NON URGENT

Symptom NOT

mentioned in CMC

care plan

NHS pathways –

disposition as per DOS

Symptom pertains to CMC care plan

Select from CMC appropriate Disposition e.g. District Nurse

111 Clinician

Public

Caller

111 Health Adviser

triages, takes caller

demographics.

If CMC flagged up…..

999

2013 NHS developing pathways

9

CMC PATIENT AND PROFESSIONAL VIDEO

10

11

2014

CMC OUTCOME DATA

12

Outcomes

Patients with CMC personalised urgent care plans 22,119

Deaths recorded 9,322

Patients who died in their preferred place 79%

Actual place of death 17% died in Hospital i.e. 83% died outside of

hospital

Death in Usual Place of Residence (home, care home)

- National data for London 16% (2011)1

- CMC – 65.1% (2015)2

Costs- £2,500 saving per patient who dies with CMC care plan i.e. cost

savings of £23.3 million

1. NEoLCIN local authority profiles using Office for National Statistics data 2009-20112. CMC Data: 19th June 2015

13

Urgent care have access to patient’s care plans 24/7

Data: Apr 2013- June 2015

Access by urgent care

2598

1792

41556% 39% 9%

0

500

1000

1500

2000

2500

3000

111 Provider AmbulanceTrust

Out Of Hour GPProvider

On average total views per month = 756

14

Increasingly, careplans are created in acute setting

Data: Apr 2013-Jun 2015

Record creation

Number and % of CMC care plans created

2669

2168

1774

751

36%

29%

24%

10%

Hospice

Acute

GP

Community

15

Partnership development

2015

&

16

A FIRST LOOK…..

17

Create Urgent Care Plan

View Urgent Care Plan

19

What differentiates CMC?

Personalised Care Plan

Single Pathway

Collaborative Care planning

Selection of paper maps vs Satellite navigation

CMC Care Plan

Integrated

Plan

Care

G

O

V

E

R

N

A

N

C

E

20

CMC

CMC

CMC

CMC

Notification (flag)

Two-way synchronization

Federation / virtualised

Subscription “I’m interested in”

G

O

V

E

R

N

A

N

C

E

Exchanging messages

21

CMC DEVELOPMENT ROADMAP

22

The Integrated Care Exchange (ICE)

23

Integrated Care Exchange

TPP

CMC

A&E systems

Biosensor data

NHS 111Cerner

LAS

Eliminate Silos

Platform for creating information

flows

September – new launch, overhauled interface

December – integrated with EMIS

March – integrated with other systems + Patient portal

April onwards - patients create first part of own care plan (CPR, ADRT, organ donation, PPC, PPD)

Coordinate My Care Roadmap

2015/16

24

Outcomes

Patient & ClinicianPatient

Coordinate My Care Roadmap (cont)

CMC care

record

CMC UrgentCare Plan

25

Empowers patients and carers

Builds confidence

Continues to put people first

CMC is hosted by The Royal Marsden NHS Foundation Trust

Created by NHS Clinicians for NHS patients

www.coordinatemycare.co.uk

CMC is hosted by The Royal Marsden NHS Foundation Trust

www.coordinatemycare.co.uk