Coordinate My Care is a clinical service built on a scalable, web-based IT platform, and has the potential to transform urgent care planning for end of life care patients across London. So what success has it achieved so far, and what lessons could be learnt to scale it up for national use? Julia Riley, Clinical Lead at Coordinate My Care in the Royal Marsden NHS Trust explains.
Coordinate My Care (CMC) is a NHS clinical service built on a scalable, web-based IT platform delivering digital, multidisciplinary, urgent care planning for end of life care (EOLC) patients across London. It offers robust information, clinical governance, clinical quality, reporting and training.
Over the last 6 years the team has delivered significant quality and financial improvements in the care provided to just under 30,000 patients, including a step change in meeting patients’ place of death preferences (17% dying in hospital vs. 47% nationally) and is saving the NHS £2,100 per patient.
“Urgent care across the NHS is often delivered in a fragmented way,” explains Julia, “Continuity of care can be weak across organisational boundaries, and coordination to ensure that patients receive urgent care at the right time, in the right setting and by the right professional, can be lacking. In addition, care is often not aligned to a patient’s wishes and preferences. This is particularly prevalent for patients suffering from long term conditions who often face long and unnecessary acute admissions, with the ensuing cost implications for the NHS.
“Patients receive care from clinicians across social, voluntary, community, primary, secondary and tertiary care. In order to coordinate care and deliver equal access based on clinical and patient need, urgent care services need access to the right personal and clinical information to allow them to make informed decisions. Care planning systems need to support this multidisciplinary working.”
Julia is keen to point out that behavioural change requires more than an IT system. “It needs a clinical service delivering a clinically designed system and the training and reporting to embed the use of urgent care planning. “CMC is closely aligned to current health and care strategy and objectives.” she adds.
“12% of all people with a care plan do not know they have one,” says Julia, “ They need a service that will allow them to initiate the creation of their own plan and will also act as an extra validator of the plan’s accuracy on an ongoing basis.”
CMC has also been designed to be scalable, robust and effective, delivering quality and cost improvements for patients and the NHS.
“Digitalisation represents disruption of working processes. In the process of the disruption, many stakeholders have an interest in working in traditional ways and thus the politics of radical change are complex.” says Julia. “For instance, CMC started as an End of Life Care Register. It was then called an Electronic Palliative Care Coordination System. Feedback from patient and carer groups as well as professional stakeholders told the team that language is important, and terms such as ‘register’ and ‘end of life care’ have poor connotations to patients, carers and professionals.”
“In terms of technology, we found that CMC’s initial IT platform, though robust and clinically safe, had a clunky interface and no interoperability functions. We learned from the initial system that the technology needed to be simple and intuitive, as well as interoperable, to enable the user to create urgent care plans from within their own native IT system.”
Other key factors which needed to be addressed were overcoming barriers to new pathways of working for 111 and 999, the need for variable design for varied plan users, safety and national standards requirements, and governance.
An NHS 111 Learning Programme showed that patients with a plan are 50% less likely to need an ambulance and 80% less likely to be referred to A&E. A Frontier Economics study found that on average a patient dying with a plan saved the NHS £2,100, driven by a reduction in A&E attendances, acute admissions and LOS. With current EOLC coverage this equates to an annual saving of over £16.8 million; and CMC delivers an 8.4:1 ROI ratio for CMC’s commissioning London CCGs.
Coordinate My Care is part of the strategic digital plan for London. It is partnered with 111, the Healthy London partnership, and the London Ambulance Service, and is funded by the 32 London CCGs which will ensure sustainability across the capital. Sustained evidence shows that CMC delivers improved quality of care and a lower cost to the NHS.
CMC underpins the enhanced service (ES) that is designed to help reduce avoidable unplanned admissions to hospital by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admission or re-admission. It also acts as a vanguard for nursing homes in line with the new model of care for patients.
CMC is part of a national drive to ensure that patients are offered the opportunity to have discussions around Advanced Care Planning.
Progress and monitoring
CMC operates a system of monthly data reviews for all users, highlighting key points and comparing CCGs to enable best practice to be identified and shared. In addition, the team runs stakeholder meetings, webinars, and newsletters, implementing feedback and lessons learnt through training materials and quality reports.
“External orientation is critical to the success of CMC,” says Julia, “The service has been designed with the end needs of the urgent care services as paramount – urgent care plans are only useful if they provide the urgent care services with the information required to deliver coordinated and patient centric care.”
“We have taken an entrepreneurial approach – developing, launching and growing the service has required pragmatism, risk taking, commercial insight and resilience. The service has been delivered by three different IT providers, different operating models have been developed to mirror funding arrangements, contracting has been developed to ensure that the service is scalable, funding has been secured to deliver a bespoke IT system and determination displayed in ensuring that CMC continues to deliver a clinical rather than an IT-led service focused on delivering benefits for patients.”
“The application of data analytics and evidence-based development is critical to the success of CMC. Understanding the impact of the service on the delivery of patient wishes such as preferred-place-of-care, the number of acute admissions avoided, and the financial benefits, are central to making the case for change and further improving the service.”
The future: national roll-out.
“My aspirations are to deliver the benefits outlined above to new patient cohorts and health economies outside London,” says Julia, “CMC should be accessible to all for the benefit of individual patients but also organisationally and financially. This will represent a service redesign at a population level and a culture shift from reactive crisis care to planned, quality care, at times of crisis.”
The cost of delivering the service nationally has not been modelled but the team believes that given the operating model, IT provider contract, and benefits of building on an existing robust NHS service, CMC could be scaled up at reducing cost increments. They estimate the saving delivered per plan for patients with long term conditions, rather than EOLC patients, would be more than £2,100.
“England’s annual EOLC population is approximately 530,000. If CMC were to deliver care planning for 50% of this population, it would equate to a huge change in compliance with patients’ preferences and an annual projected saving of over £556 million.” Julia adds.
“Qualitatively the existence of a plan has given patients and their families reassurance that their wishes will be taken into account in the event of an urgent care episode.
And in the words of recent patients: “Now I have the plan, I feel so much happier. Because I’ve got some control over things. I will probably need urgent care in the middle of the night again – that’s how cancer goes. But, this time, everyone will know what to do with me. They’ll know exactly what I have, and how it’s being treated. I won’t have to explain it all and repeat myself to different people, when I’m too distressed to speak. I’ll get the right painkillers, at the right time. And I’ll be in my own home, instead of sitting in pain in A&E. I’ll get the care I need, the way I want it.”