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Created by NHS Clinicians for NHS patients
Creating & sharing urgent care plans
The problems facing Urgent Care
2014/1511.9 million calls to NHS 111
2 million Category A Ambulance calls22 million A&E attendances
5.5 million emergency admissions70%+ acute bed days
Unnecessary admissions e.g. 75% of asthma admissions are ‘unnecessary’
Why?• Lack of patient level planning
• Lack of sharing of key patient information across care boundaries• Lack of patient engagement in their own care
Coordinate My Care (CMC)
CMC Urgent Care Plans: what are they?
• Now documents about the future• A record of the courageous work of the patient
combined with the skilled work of the clinical team• Headlines and highlights from the patient and
about the patient shared safely across buildings, across services and across time
• Making the known patient care plan known to Urgent Care Services 24/7
The impact of CMC
CMC Activity
•30,000+ plans created•Av. 750 added per month•Av. 700 urgent care accesses per month
48%
23% 23%
5%
18%
39%
25%
18%
Hospital Home Care Home Hospice
England ² CMC ¹Actual place of death
1. 1st April 2016 – 31st July 2016 / 2. NEOLCIN, 2014-15
Patient preferences Ambulance & ED referrals Financial impact
69.3%5.6%
25.1% Met PPD1
Met PPD2
Not met PPD
Av. £2,100 saving per patient with a CMC plan by reducing emergency admissions and hospital transfer costs
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
Key themes of successful urgent care planning
One standard up-to-date multi-disciplinary digital urgent care plan
per patient
One…Urgent care
services want a standardised
‘one version’ of the truth
Up-to-date…Urgent care
services do not want to worry about out-of-
date information
Planned…Urgent care
services want treatment plans
and interventions
Multi-disciplinary…Urgent care
services want to see information from a patient’s
whole care team
Digital…Urgent care
services want quick and easy access to the
plan
1 2 3 4 5
CMC - A clinical service supported by IT
CMC Clinical Service
CMC IT System
• Clinically lead• Change
management• Clinical & system
training• Management
information• Clinical research• Quality reporting
• Digital• Standards based• Standardisation
model• Intuitive
professionals & patient interface
• Highly accessible• Interoperable
One digital standard urgent care plan per patient
NHS 111
Out of Hours GPs
Urgent Care
Centres
A&Es
GPs
Hospitals
Community Services
Patients
Marie Curie, Macmillan &
Specialist Nurses
Social Services
Care Home & Nursing
HomesHospices
Ambulance Service
All members of each patient’s day-to-day care team share the responsibility for maintaining one standard up-to-date multi-disciplinary digital urgent care plan to which urgent care services have access
Standard urgent care plan
• Enabler for standardised care and coordination
• Supports collaborative, multidisciplinary use
• Proven interoperability strategy and roadmap
• End of Life Care Plan (ISB 1580)
• Crisis Care Extract
Non-Urgent Care: data aggregated for interpretation by clinician
AGGREGATION MODEL
One standard urgent care plan per patient
Acute hospital
Social care
GP
Hospice
Community teams
Care homes
Urgent Care: single version of relevant data only
STANDARDISATION MODEL
Acute hospital
Social care
GP
Hospice
Community teams
Care homes
Non-Urgent Care Clinician has time, & patient knowledge, to interpret/benefit from a collection of diverse and potentially contradictory information
Urgent Care Clinician requires a standardised, high quality action plan without superfluous or duplicated information
Intuitive & user friendly professionals interface
Drives MDT use & regular reviews
Easy patient search aligned to PDS / Spine
Intuitive plan creation process Urgent care summary
Highly interoperable solution - Current
Coordinate My Care
Social Care
Care Homes
Hospices
Acutes
GPs
MDT urgent care plans
LAS OOH 111 A&E
In-context links
Auto-flagging
CMC User-InterfaceWeb based & mobile
accessible
Social Care
Care Homes & Nursing Homes
HospicesAcutes
GPs
PRM
MyCare
LAS OOH 111 A&E
Standards based integration
111 PRM
Coordinate My Care
MDT urgent care plans
Highly interoperable solution - Future
MyCare: Patient interface
• Drives patient engagement and ownership
• Places patients at the centre of urgent care planning
• Supports health providers to keep the care plans live and up-to-date
• Supports the growth of urgent care planning
• Allows:o Patient enrolment &
viewo Patient initiationo Patient editing
CMC - A clinical service supported by IT
15
CMC Clinical Service
CMC IT System
• Clinically lead• Change
management• Clinical & system
training• Management
information• Clinical research• Quality reporting
• Digital• Standards based• Interpretation
model• Intuitive
professionals & patient interface
• Highly accessible• Interoperable
Clinical & system training is critical
• Online training programme• Face-2-face training• Training focused on:
o Systemo Clinical: Patient consent Mental capacity Advance care planning
Embed use of plans in urgent care pathways
Call transferred to Clinical Hub
111 Clinician accesses the CMC care plan
Ambulance dispatched
Clinical hub relays CMC care plan information to
paramedics to inform immediate management
Public call to LAS1
NHS Pathways – disposition as per
DOS
Select appropriate disposition e.g. district nursing
Ambulance dispatched
NON URGENTSymptom NOT on the CMC care plan e.g. flu
NON URGENTSymptom pertains to CMC care plan e.g.
pain control
URGENTSymptom 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
Management information is key to driving change
•Organisation level e.g. GP practice to CCG•Geographical e.g. CCG to STP•Granular activity monitoring e.g. view and edit access, data quality measures, smartcard & in-context SSO usage•Range of KPIs e.g. PPD achieved percentage, coverage of expected EoLC patient cohorts•Service feedback e.g. useful vs. non-useful
A focus on quality
Bad
•PPC: Not yet discussed•PPD: Not yet discussed•CPR: Not yet decided•Ceiling of Treatment: Empty•Treatment Plan: Empty•Contacts: None
Good
• PPC: Hospital• PPD: Home• CPR: decided – Yes or No• Ceiling of Treatment - given• Treatment Plan: Symptoms/Actions• Contacts: Family & professional
Clinicians should ask these questions: • Will the care plan content support Urgent Care Services in delivering the desired
patient care?• Will the way I have created the care plan support Urgent Care Services? (no large copy
and pastes)
‘Think 2 am’ – which one supports 111/OOHGP/LAS to support your patient?
88%84
67 66
77
21
42
25
83
0
1
2
3
4
5
6
1 2 3 4 5 6 7 8 9
5811 CMC Urgent Care Plans Nov 2015 – August 2016 – Quality Overview
Potential Item Engagement Actual Item Engagement
Preferences & Prognosis Advance Treatment Plan Contacts & Published Cycle1 - PPC 4 - Ceiling of Treatment 7 - Personal Contacts2- PPD 5 - CPR Decision 8 - Contacts – Professional
3 – Prognosis 6 - Symptom Treatment Plans
9 - Approval Gap
“One standard up-to-date multi-disciplinary digital
urgent care plan per patient”
