Primary and community care

The tools developed for I-CARE & Share have been extensively tested across several Places and have a proven track record within general practice and community services.

Phase 1

Primary and community care was selected as phase 1 for the following reasons:

General practice and community care manage the majority of palliative care patients.
Care homes are situated in the community.
350 general practices are covered by just two IT systems, enabling quicker scale-up
General practices have an obligation under the PCN DES to care plan care home patients. I-CARE & Share processes cover the NHS England requirements for this contractual obligation.
There is an urgency to help patients wishing to stay at home to do so – especially given the pressures within the urgent and emergency care system.
The wide variety of care plan types, quality and frequency across Cheshire and Merseyside warranted priority focus.

General practitioners and community care staff are highly trained in managing complex, frail and palliative care patients.

I-CARE & Share provides new tools to enable this to be more comprehensive and ensure their clinical care decisions influence other services appropriately.

Identification

All practices should have a palliative care register with a minimum of 0.6% of the practice population.
If the register is lower than this, consider using the EARLY tool (EMIS search) to identify patients who are likely to die in the next 6-12 months

Communication

All initial Personalised Care Plans and DNACPR discussions should be conducted face to face with the patients and immediate carers or family. Using the Personalised Care Plan has been found to be a helpful framework.

Anticipatory Care Plan

The Personalised Care Plan template covers this

Resuscitation Decision

Discuss thoughts, feelings and decisions in regard to a cardiopulmonary resuscitation decision.
If applicable, use the North West Unified Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) form.
Problem code "Not for cardiopulmonary resuscitation" if this is the outcome for the patient

Escalation Plan

The Personalised Care Plan template covers this

Share with other providers

Save the Personalised Care Plan On the EMIS record
Provide a printed copy to the patient/ carers
Send a copy electronically to your GP OOH service

The process for a palliative patient is summarised below:

I CARE & Share Internal GP IT Processes V1.4

Frequently asked questions

Does this process cover the PCN DES?

Yes, I-CARE & Share tools cover the PCN DES requirement of care planning care home residents on admission. In particular:

It references the six common geriatric assessment domains necessary
Covers all key questions for care home residents
Is flexible and has been proven to be used by a variety of PCN clinicians including nurses and pharmacists

Is I-CARE & Share contractually obligated?

Primarily, I-CARE & Share is about doing what is in the patient’s best interest, seeking to coordinate care, avert crises, and prevent futile intervention and distressing experiences.

It is currently down to respective Places as to whether the use of I-CARE & Share is obligated within the respective GP contract

How do I share with North West Ambulance Service (NWAS)

North West Ambulance Service currently do not have a mechanism to flag that a patient has a care plan. This is something we are seeking to influence.

It is therefore crucial to empower carers to ensure they can present a care plan on engaging the ambulance service by giving them a printed copy with advice.

How do I share with my GP-OOH

This will depend on the IT system your GP-OOH provider is on. If your GP-OOH provider has access to documentation via EMIS sharing, then sharing is already covered.

For Places where the GP-OOH provider uses Adastra the following is in Place:

Request an Adastra Web Access Login for respective administrators
Upload the Personalised Care Plan to the portal

Your Place Clinical Lead will be able to advise.

What can the hospitals see?

As the coding within the I-CARE & Share template is EPaCCs compliant, key codes are visible on the hospital electronic health record through e-exchange or equivalent interoperability process.

https://www.england.nhs.uk/north-west/north-west-coast-strategic-clinical-networks/our-networks/palliative-and-end-of-life-care/for-professionals/electronic-palliative-care-coordinating-systems-epaccs/

This is one reason why completion of the template is necessary.

Hospitals can also see the Personalised Care Plan through EMIS if they choose to request access however this is not common.

Do I still need to complete a ‘special note’ to my GP-OOH provider?

For care home patients and palliative care patients the I-CARE & Share Care Plan covers the need to complete a special note. This may still be required for other reasons (for example, drug dependency).

Why can’t I just use ReSPECT or my own care planning tools?

The ReSPECT form was introduced by the Resuscitation Council in 2016. It was a positive step forward, incorporating some aspects of personalised care planning within the structure of a DNACPR form.

However, PEoLC Network audits across Cheshire and Merseyside demonstrated that in the main ReSPECT was merely being used as DNACPR form and effective care planning was not being completed.

On review many care plans have been developed across Cheshire and Merseyside. However, we frequently found that key parameters were missing and as such the value of the care plan was limited. Urgent care staff could not access the plan, reducing the effectiveness of the process. Having the same plan and process across a Place increases familiarity, strengthening use and impact.

The table below explains the differences between the two approaches and advantages of using I-CARE & Share over ReSPECT.

	I-CARE & Share PCP	ReSPECT
DNACPR	NW uDNAR	✓
Escalation thresholds	✓	✓
Personal preferences	✓	✓
Shareable	Word file	Word file
GP / Clinician contacts	✓	✘
Suitable for PCN DES (CGA)	✓	✘
Specifies significant docs	✓	✘
Advance / Anticipatory Care Plan	✓	✘
Baseline function	✓	✘
Significant problems	✓	✘
Codifies key data onto record	✓	✘
Meets EPaCCS standard	✓	✘
Success measurable through business intelligence (BI)	✓	✘