Professor Julia Riley, Clinical Lead, Coordinate My Care
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Transcript of Professor Julia Riley, Clinical Lead, Coordinate My Care
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
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
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%
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 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