Dying well at home: the case for integrated working
Practice example 7: Coordinate My Care: joining up London’s end of life care services
Coordinate My Care (CMC) is a clinical service that coordinates care. It provides a care pathway that enables health professionals from primary, secondary and community care to put the patient at the centre of healthcare delivery. It is integrated with NHS 111 and designed to facilitate and strengthen communication across care settings. Modern technology is at the centre of the service, making information accessible 24/7 to professionals responsible for delivering coordinated care.
The service has been developed to encourage patient choice and to preserve dignity and autonomy at the end of life.
At the heart of CMC is a care plan that is developed by a patient with their nurse or doctor if and when both feel that it is appropriate. It contains information about the person and their diagnosis, key contact details of their regular carers and clinicians, and their wishes and preferences in a range of possible circumstances. This care plan is uploaded to the CMC system to which only trained professionals involved in their care can have access. These include ambulance control staff, NHS 111 operators, GPs, out-of-hours GP services, hospitals, nursing and care homes, hospices and community nursing teams.
The delivery model comprises a comprehensive training programme underpinned by a central web-based service that allows visibility to care providers. Over 5,000 healthcare professionals have been trained to use the service.
Across London, there are 5,273 CMC patient records that contain patients’ wishes and state their care plan. Over the past 23 months, 1,339 patients on CMC have died: 78 per cent in the community (34 per cent at home, 30 per cent in a care home and 14 per cent in a hospice), 21 per cent in hospital and one per cent in other locations. Twenty-seven per cent had no place of death recorded. By comparison, 2010 Office for National Statistics data for London reported that 59 per cent of patients died in hospital. Of those CMC patients who had a preferred place of death documented, 80 per cent died in their preferred place of death.
Julia Riley, Head of the Department of Palliative Medicine and Clinical Lead for Coordinate My Care.