joined up health and care · urgent care have access to patient’s care plans 24/7 data: apr 2013-...
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CMC is hosted by The Royal Marsden NHS Foundation Trust
Joined up Health and Care
Dr Julia Riley - CMC Clinical Lead
29 June 2015
Created by NHS Clinicians for NHS patients
• Patient centric care plans
• Medical
• Nursing
• Social
• Financial
• Spiritual
• Cultural
• Multiple faxing
• Not contemporaneous
2007
Introduction of ‘Hospital2Home’
4
• EoLC strategy
• DH Pilots
• London x 2
Hospital2Home development.....datasets
Sutton and Merton
Camden and Islington
2008
6
• Coordinate My Care
• Pan London
• EoLC
• Connect to London Ambulance Service
• NHS 111
• GP OOH
2010
Coordinate My Care – Pan London
7
Coordinate My Care – Pan London
• Built on Social Services platform
• Robust
• No clinical incidents related to IT
HOWEVER
• ‘Cluncky’
• Lack of interoperability
• Not intuitive
2010
8
URGENTSymptom NOT on
CMC care plan
999
NON URGENT
Symptom NOT
mentioned in CMC
care plan
NHS pathways –
disposition as per DOS
Symptom pertains to CMC care plan
Select from CMC appropriate Disposition e.g. District Nurse
111 Clinician
Public
Caller
111 Health Adviser
triages, takes caller
demographics.
If CMC flagged up…..
999
2013 NHS developing pathways
9
Outcomes
Patients with CMC personalised urgent care plans 22,119
Deaths recorded 9,322
Patients who died in their preferred place 79%
Actual place of death 17% died in Hospital i.e. 83% died outside of
hospital
Death in Usual Place of Residence (home, care home)
- National data for London 16% (2011)1
- CMC – 65.1% (2015)2
Costs- £2,500 saving per patient who dies with CMC care plan i.e. cost
savings of £23.3 million
1. NEoLCIN local authority profiles using Office for National Statistics data 2009-20112. CMC Data: 19th June 2015
13
Urgent care have access to patient’s care plans 24/7
Data: Apr 2013- June 2015
Access by urgent care
2598
1792
41556% 39% 9%
0
500
1000
1500
2000
2500
3000
111 Provider AmbulanceTrust
Out Of Hour GPProvider
On average total views per month = 756
14
Increasingly, careplans are created in acute setting
Data: Apr 2013-Jun 2015
Record creation
Number and % of CMC care plans created
2669
2168
1774
751
36%
29%
24%
10%
Hospice
Acute
GP
Community
15
What differentiates CMC?
Personalised Care Plan
Single Pathway
Collaborative Care planning
Selection of paper maps vs Satellite navigation
CMC Care Plan
Integrated
Plan
Care
G
O
V
E
R
N
A
N
C
E
20
CMC
CMC
CMC
CMC
Notification (flag)
Two-way synchronization
Federation / virtualised
Subscription “I’m interested in”
G
O
V
E
R
N
A
N
C
E
Exchanging messages
21
The Integrated Care Exchange (ICE)
23
Integrated Care Exchange
TPP
CMC
A&E systems
Biosensor data
NHS 111Cerner
LAS
Eliminate Silos
Platform for creating information
flows
September – new launch, overhauled interface
December – integrated with EMIS
March – integrated with other systems + Patient portal
April onwards - patients create first part of own care plan (CPR, ADRT, organ donation, PPC, PPD)
Coordinate My Care Roadmap
2015/16
24
Outcomes
Patient & ClinicianPatient
Coordinate My Care Roadmap (cont)
CMC care
record
CMC UrgentCare Plan
25
Empowers patients and carers
Builds confidence
Continues to put people first
CMC is hosted by The Royal Marsden NHS Foundation Trust
Created by NHS Clinicians for NHS patients
www.coordinatemycare.co.uk