Coordinate My Care: enabling patient choice when it matters most

Over 500,000 people die in England and Wales every year, and almost half of those die in hospital – despite the fact that just 3% of people say that is where they want to spend their final days.

Statistics such as these highlight why the Coordinate My Care service is so important, beginning in London's Royal Marsden Hospital as a way of recording an individual’s end-of-life care wishes.

Now, the service not only captures patient wishes; it is sharing this information between the capital’s multiple health and care providers, especially when urgent care is required for all patients, not only those who are terminally ill.

Working with London's 32 clinical commissioning groups, GPs, out-of-hours services, 111 service providers, the London Ambulance Service - and based on InterSystems’ health information sharing platform HealthShare - Coordinate My Care has developed into an intuitive, personalised urgent care plan that is putting patient choice at the heart of healthcare.

Beforehand, we were not sure what the care plan was and may have taken people to hospital when it was not the best thing for the them. This system has changed that, so patients can receive the care they want

By sharing patient wishes at times of most need, the programme is helping people receive care in the place they would like, most usually the home.

And, at a time of financial pressures, the programme is also saving tens of millions of pounds across the capital, and could save England’s NHS over £500m if it was implemented across the country.

Respecting patients’ wishes

Coordinate My Care enables patients to work with their care providers – usually their GP – to discuss and record their wishes and enable those plans to be shared with the urgent care providers, during the out-of-hours period when urgent care may be required.

It does this through a web-based interface that asks essential questions about their care, including their medical needs, as well as their preferences for any social, nursing, spiritual, and cultural needs. At all times the patient can review the plans on their smart phones.

Immediately a CMC urgent care plan is created and care providers, such as their GP’s out-of-hours provider, 111, or the ambulance service are automatically alerted that the patient has an urgent care plan and can treat them accordingly.

Coordinate My Care worked with InterSystems to develop an electronic urgent care plan using InterSystems HealthShare to make it easy for mobile and office-based care providers to use the system.

This is a clinical service that co-ordinates care around the patient, outside of the times when their GP is available

HealthShare harnesses information from a number of systems and feeds it into HealthShare’s urgent care management application, which is used to access and edit the care plan.

Additional information is added by the patient's GP or nurse in discussion with the patient.

This information is then shared with care providers, with the appropriate consent.

Patients can access the plans, which are reviewed when appropriate to ensure that a patient’s wishes are current.

To support this review process, reminders are sent to the person’s GP and escalated to others involved in the patient’s care if no action is taken.

Updated care plans are notified to all urgent care providers so that they know that they are viewing the latest care plan.

Users of EMIS, the largest IT supplier to GPs in London, can see directly from their screens when such a plan is in place.

The system is highy usable and works with existing NHS infrastructure.

With a browser-based and adaptive interface, it works across mobile and office devices, ensuring that as many people as possible can see and act on the information.

Impact on patients and professionals

The results for Coordinate My Care are impressive. It is in use in over 1,000 GP practices across London; with over 35,000 plans having been created, up by more than 10,000 in 2016 alone, thanks in part to its strong ability to share information across vital care providers and its simple user interface.

Records show that for those Coordinate My Care patients who have passed away, 78% died in their preferred place.

One in five are dying in hospital, rather than almost 50% doing so at a national level.

Care providers are seeing a similar transformative impact.

Paramedics have information available via mobile devices, enabling them to make crucial decisions that reflect the patient’s choice.

David Whitmore, senior clinical advisor at the London Ambulance Service, said: “Coordinate My Care plans have radically changed the way patients are treated.

Out-of-hours and 111 operators have access to a much-more-rounded view of the patient, meaning they can determine the best course of action suited to a patient's wishes, which helps them provide better care and reduce the number of unnecessary hospital admissions

"Beforehand, we were not sure what the care plan was and may have taken people to hospital when it was not the best thing for the them.

“This system has changed that, so patients can receive the care they want. Now treatment can take place in the home, which is preferable.

Out-of-hours and 111 operators have access to a much-more-rounded view of the patient, meaning they can determine the best course of action suited to a patient's wishes, which helps them provide better care and reduce the number of unnecessary hospital admissions.

Corodinate My Care is a clinical change management service that changes care from re-active care to planned care, from crises and A&E admissions to elective, planned, less-costly care, closer to home.

“This is a clinical service that co-ordinates care around the patient, outside of the times when their GP is available,” said Professor Julia Riley, a consultant in palliative medicine and clinical lead for Coordinate My Care.

“It supports patients virtually to deliver the care they need.”

While the care benefits are considerable, the financial benefits are equally impressive.

Coordinate My Care is, on average, saving the NHS £2,100 per patient, equating to an annual saving of over £16.8m in London alone.

If implemented throughout England, projections for annual savings would be over £556m.

The next steps

Coordinate My Care is supporting the co-ordination of care through the sharing of secure information with health professionals for thousands across London.

Its success has led to the initiative being listed on the NHS Innovation Accelerators programme, which seeks to promote evidence-based and cost-saving initiatives that focus on providing solutions to key challenges facing the NHS.

It is also well regarded by other regions looking at how they can best serve the urgent care plan needs of patients and professionals affected by end-of-life care and chronic illness and those who are making plans for patients are identified as having a high eFrailty index.

InterSystems and Coordinate My Care are also working with electronic patient record providers so that the plan can be viewed and updated in multiple care settings, using NHS Digital’s emerging standards for interoperability, including HL7 and FHIR.

And one of the important next steps for the project is to enable patients to edit their own record, so they can enter their own preferences for further discussion with their GP or other care provider.