Kernowhealthcic.enquiries@nhs.net   |   01872 221102

Coordinate My Care

Coordinate My Care (CMC) is a digital NHS advance care planning service that supports people with long term health conditions, and those at the end of their life, to live their final days in the way they wish.

For patients with a CMC care plan, created in partnership with their family and clinicians, everyone they meet along their health and care journey knows their diagnosis, how they wish to be managed and what to do in the middle of the night when their own doctors and nurses may not be available.

 

Benefits of CMC

  • Supports patients to express and co-design their wishes about how and where they are treated.
  • Enables all healthcare professionals to offer more personalised medical care, with full respect to each patient’s preferences.
  • Promotes system flow through digitally enabled community services and shared-care platforms enhancing care, reducing costs, and improving bed availability.
  • Reduces information scarcity across the system and promote cross organisational working.

 

CMC in Cornwall

Kernow Health CIC is coordinating the roll-out of Coordinate My Care (CMC) across Cornwall on behalf of NHS Kernow and is working in collaboration with primary care networks (PCNs), community teams, hospices, South Western Ambulance Service NHS Foundation Trust, emergency departments, 111 integrated urgent care services, patient advisory groups, adult social care, and the voluntary sector.

CMC will be initially trialled in PCNs who have volunteered to be early adopters, with a formal review being undertaken to inform the strategy of the ongoing consecutive roll out.

 

Case Studies

How CMC works

Starting point 1

CMC allows a patient to start their own care plan via the patient portal MyCMC. They complete an online questionnaire which they submit to a clinician for approval. Once a patient has submitted their online questionnaire, MyCMC then sends an automated email to your organisation to highlight that a plan needs to be actioned. Please note for GPs this will be sent to the generic GP practice email inbox to action.

Clinicians can access the MyCMC patient questionnaire via the ‘create button’ in their action needed list (or if they have accessed the patients CMC directly via EMIS or VISION). Here, the patient’s entries can be accepted which will then auto populate directly into a new CMC care plan.

Finally the mandatory clinical fields are completed, which include medical background, prognosis, CPR and emergency treatment plan.

At any point the patient can make an appointment to see their clinician to progress their CMC plan. Once approved by a clinician this plan is now ready to be viewed by urgent care services.

Training is being provided for social prescribers, adult social care workers, care home staff, day care providers, and the voluntary sector enabling them to support patients completing MyCMC. We are also working with teams regarding digital inclusivity.

Starting point 2

Clinicians, for example GP’s, specialist palliative care nurse, district nurse, community matron or consultants, initiate a CMC plan once consent has been obtained.

Clinicians work with patients and their families to create a CMC plan that respects the individual’s clinical needs, wishes and care preferences. Once the care plan is completed, a clinician will approve it and upload it onto the CMC system. The CMC plan can then be viewed by those with a legitimate relationship to the patient, allowing urgent care practitioners and healthcare providers to have 24/7 electronic viewing access to the CMC plan to guide their response to the patient’s needs. Care plans can be edited by clinicians and patients can request edits via the MyCMC system if they have been enrolled by their clinician

Training and accountability

To ensure information governance standards are maintained, it is essential that clinicians and plan viewers complete training before requesting user access and commencing use of the CMC system.

The training available is dependent on the type of access required.

Which roles are assigned to each level of access rights?
Organisations should only assign clinical rights to trained and competent clinicians. It is an organisational decision whether emergency department staff should be assigned clinical or urgent care access.

What CMC training is required for each level of access?
The accountability of ensuring staff are sufficiently trained lies with the care provider organisations, as per the agreement co-signed by CMC and the organisation. CMC offer a wide variety of training including webinars and online training modules. Users are asked to self-select the type of training that they have undertaken.

Roles include Access required Training session required Session length
Voluntary sector worker, social prescriber, community maker or patient support No access to CMC system Supporting patients with MyCMC

 

30 mins
Urgent care teams, out of hours GPs, emergency departments, paramedics, healthcare assistants, social care workers, ward administrators, nurses or Hospice staff View plans CMC system training 30 mins plus additional online resources session delivered by a trainer or self-learning.

 

GP, nurse, consultant or occupational therapist Clinical access to create plans with patients and publish to CMC Clinical training 1 hour plus additional online resources
IT requirements

CMC is currently interoperable with EMIS, SystemOne and Adastra. CMC can be launched via an in-context link within these systems.

CMC is also live in the national record locator enabling care plans to be searched for and viewed.

Where other systems are used a URL is available and can be added to the desktop or bookmarked.

To get started an information sharing agreement (ISA) is required from each organisation along with contact details for key members of staff.

Ongoing support and guidance is available from Kernow Health CIC and Coordinate My Care.