The document discusses creating and sharing urgent care plans to improve coordination of care for patients. It notes problems like unnecessary emergency admissions and lack of patient information sharing. Coordinate My Care (CMC) creates digital urgent care plans with input from clinical teams to be accessed across services. CMC plans have led to more patients' end of life preferences being met, lower ambulance and emergency department referrals, and savings of around £2,100 per patient by reducing admissions. The key to successful urgent care planning is having a single, up-to-date, multi-disciplinary digital plan for each patient that can be accessed by urgent care services.

1. Created by NHS Clinicians for NHS patients
Creating & sharing
urgent care plans

2. The problems facing Urgent Care
2014/15
11.9 million calls to NHS 111
2 million Category A Ambulance calls
22 million A&E attendances
5.5 million emergency admissions
70%+ 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

3. Coordinate My Care (CMC)

4. 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

5. 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
6 9 .3 %
5 .6 %
2 5 .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

6. 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

7. 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

8. 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
Homes
Hospices
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

9. 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

10. 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

11. Intuitive & user friendly professionals interface
Drives MDT use & regular
reviews
Easy patient search aligned to
PDS / Spine
Intuitive plan creation process Urgent care summary

12. 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-Interface
Web based & mobile
accessible

13. Social Care
Care Homes &
Nursing Homes
Hospices
Acutes
GPs
PRM
MyCare
LAS OOH 111 A&E
Standards based
integration
111 PRM
Coordinate My Care
MDT urgent care plans
Highly interoperable solution - Future

14. 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 &
view
o Patient initiation
o Patient editing

15. 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

16. Clinical & system training is critical
• Online training programme
• Face-2-face training
• Training focused on:
o System
o Clinical:
 Patient consent
 Mental capacity
 Advance care planning

17. 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 LAS
1
NHS Pathways –
disposition as per
DOS
Select appropriate
disposition e.g.
district nursing
Ambulance
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

18. 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

19. 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?

20. 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 Cycle
1 - PPC 4 - Ceiling of Treatment 7 - Personal Contacts
2- PPD 5 - CPR Decision 8 - Contacts – Professional
3 – Prognosis 6 - Symptom Treatment
Plans
9 - Approval Gap

21. “One standard up-to-date
multi-disciplinary digital
urgent care plan per
patient”