13 Coordinate my care: increasing prevalence among COPD patients

Backgrounds Coordinate My Care (CMC) is a London-based initiative which aims to make patient advanced care plans (ACP) accessible across trusts and within the community. Established in 2012, CMC is a relatively new form of ACP and although evidence indicates high useage by paramedics, CMC frequency among patients with life-limiting conditions is low. Aims We aimed to implement a series of system-based changes to increase the number of CMC records from 22% to at least 50% among chronic obstructive pulmonary disease (COPD) patients known to the Integrated Respiratory Team (IRT) who were nearing the end of life. Methods We implemented two Plan, Do, Study, Act cycles (PDSA) based on discussions with IRT. Throughout the first PDSA cycle we introduced a palliative care nurse at weekly IRT meetings to facilitate discussion of CMC. During PDSA cycle two we ensured that patient specific pathways (PSPs), a form of ACP kept by the patient in case of emergency, were uploaded onto CMC. Results Over 12 weeks, we increased the percentage of patients with CMC records to 24.4% after PDSA cycle 1% and 34.2% after PDSA cycle 2 (increase of 2.4% and 12.2% from the baseline respectively). Discussion Whilst keeping a palliative care nurse in IRT meetings may not be a long-term, maintainable, cost-effective intervention, we hope that uploading PSPs onto CMC will be a sustainable change as it is low-cost and time efficient. Making these procedural changes through identifying problems within the team, we hope that these initiatives could be applied to a wider patient population.