Coordinate My Care

Project overview

The Health Innovation Network (HIN) has been working in partnership with Coordinate My Care (CMC), to explore implementing CMC, an electronic urgent care planning service, in care homes.

CMC is a digital solution to “Advance Care Planning” currently available in London. It enables patient’s wishes and clinical recommendations about future care to be viewed by health and social care providers who have CMC access and a legitimate relationship with the patient. As a digital solution, this includes access by urgent care providers, including the ambulance service, the 111 service, GP out of hours services and hospital emergency departments.

CMC supports the provision of more person-centred care, giving a voice to the patient on how and where they wish to be cared for, as well as enabling them to only have to tell their story once. It also helps reduce the risk of inappropriate hospital admissions, reducing stress for residents and their families.

The service is beneficial for people with long term conditions or multiple co morbidities as well as people living with frailty, dementia or a mental health condition.

CMC plans are making a difference to the quality and personalisation of care received.  Three quarters of people with a CMC plan died in their preferred place of choice and less die in hospital (18% of people with a CMC plan compared to 54% without a CMC plan died in hospital). The care plan also reduces unnecessary and unwanted hospital admissions.

Despite the opportunity and benefits to care home residents in having a CMC plan, the CMC service has not yet entered the care home setting. The HIN worked with 10 south London care homes and their staff to create CMC plans for 251 residents over an 18- month period.

This found that care home staff can play an important role in creating CMC shared digital urgent care plans given the right resources and training.

The project identified key processes to enable a successful transition to CMC planning and include:

  • Achieving ‘Standards Met’ on the NHS Digital Data Security and Protection Toolkit (DSPT)
  • (If appropriate) obtaining approval and support from the Corporate care home provider (e.g. IG and IT support)
  • Establishing a collaborative working arrangement with the care home GP(s)
  • Confidence (possibly training) in having ACP discussions with residents and relatives
  • Securing some protected time and/or capacity initially, to embed CMC planning
  • Identifying positive leadership albeit the care home manager, clinical lead or GP whilst transitioning to this new way of working.

Read the final report for the Lambeth CMC pilot project here.

Read the report here.

The HIN has also produced a CMC Implementation Guide for care homes and commissioners. See the implementation guide here.

For more information about the CMC service go to –

Wessex AHSN and the London Clinical Network have developed a national training resource for frailty. See the resource here.

Watch below a ten minute video demonstrating how to produce a CMC plan quickly, created by Dr Lyndsey Williams, NHS Brent Clinical Commissioning Group.

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