Coordinate My Care (CMC) is a pan-London service working to improve patient end-of-life and urgent care by making patient wishes about their care available to healthcare professionals including GPs, hospitals, hospices and urgent care services (LAS included). CMC care plans are important as GP surgeries are only open for 30% of a patient’s week - meaning that 70% of the time - your patients are treated or advised by other healthcare professionals who do not know them.
CMC care plans can (and should) be created for any patient identified as having complex or palliative/end-of-life care needs.
All Islington GP practices have access to CMC. You can access a patient’s CMC care plan via the in-context link in EMIS. Accessing CMC using EMIS - How To Guide (PDF)
Care Plans can be created in CMC by any clinician treating the patient. Patients can also create their own care plan via My CMC.
Creating a Patient Care Plan Record in CMC
Coordinate My Care care plans are created only with consent. Ideally, the patient consents to the creation of a care plan after discussion with a healthcare professional who knows them well. However, if the patient lacks the mental capacity to consent, then the patient’s health and welfare lasting power of attorney can consent on the patient’s behalf. If the patient has not designated a health and welfare lasting power of attorney, the patient’s clinical team can make a decision in the patient’s best interest, preferably after discussion with the patient’s family. At any time consent can be withdrawn, and the CMC care plan will be removed.
The care plan is at the heart of CMC. It is developed with a patient by their healthcare professional, if and when both feel it is appropriate. The care plan contains information about the patient and their diagnosis, key contact details of their regular carers and clinicians, and their wishes and preferences in a range of possible circumstances. Care plans are available on the CMC system to which only trained professionals involved in their care can have access. These include ambulance control staff, NHS 111 operators, GPs, out-of-hours GP services, hospitals, nursing and care homes, hospices and community nursing teams.
A Coordinate My Care care plan allows healthcare providers to record significant information from and about the patient, including:
- Diagnoses and prognosis
- Contact details for professional care team and family
- Social support structure
- Preferred places of care and death
- Decisions about resuscitation
- Anticipated problems and guidance on their immediate management
A CMC care plan should not be too detailed and should only contain crucial information.
Important note: Urgent care staff can only view care plans in a published state, i.e. not in draft or needing approval state. Please ensure that care plans are completed and published as soon as possible, and reviewed at least annually.
Administrative users have the ability to create a new care plan record on behalf of a clinical colleague. They can also edit the record, adding or removing information at the request of a clinical colleague. The care plan will remain in the state Draft – needs finalisation until the user believes that the information in the record is complete and submits the care plan for approval. Usually by the clinical user who requested the care plan be created or edited.
Please ensure that the care plan is approved and published once finalised.
For further guidance on using CMC, visit the CMC website.
Any patient in London with:
- complex healthcare needs
- end-of-life/palliative care needs.