Skip to content


“I should only need to tell my story once” Giving care home residents a voice

Giving residents a voice on how they wish to be cared for by embedding Coordinate My Care into the care home sector. Delivering quality improvement between health and social care.

Read comments 11
  • Winning idea
  • 2018

Meet the team: #CMChearmywishes


  • Rebecca Newman: Project Manager across the Healthy Ageing & Patient Safety teams at the Health Innovation Network.

Do you deserve to have your wishes heard? Do you want to have a say in the healthcare you receive? If so, why should our relatives and loved ones living in care homes be treated any differently?  


Coordinate My Care (CMC) is an NHS service, sharing urgent care plans electronically between healthcare providers allowing for coordinated patient care and improved care outcomes. CMC was started by Professor Julia Riley, a palliative care consultant who had seen her own sister-in-law struggle to have her wishes followed as she died from cancer. Recently featured on channel 4 News, this pan-London service that has been awarded National Innovator Accelerator (NIA) status by the NHS. It’s the first electronic patient care plan record all healthcare providers can access 24/7, including the London Ambulance Service. An economic evaluation report has also found the average cost of treating patients with a CMC care plan is £2,102 lower than non-CMC patients in the last six months of life. There is great importance of reducing end of life care admissions from care home as part of the national frailty agenda – scaling up some of the learning from the Vanguards who have reduced admissions from care home by 20-30%.  

CH4 Link


The care home sector continues to be an under resourced, overstretched and faced with ageing population. In many boroughs only a handful of CMC care plans have been created for care home residents. Across London there are over 13,000 nursing home residents, not including residential homes. It is stated for nursing home residents’ the probability of surviving beyond one year is 48.6% (Hicks, Black & Rabins, 2010). This means that one can estimate half the residents in the nursing home will die within the year, suggesting all residents in the nursing home should have an urgent care plan.

For CMC to reach its full potential, it is essential care home staff can view and (where appropriate) edit resident’s CMC records. This is a crucial enabler for patient empowerment and to optimise quality care. Information Governance has historically been the main barrier for care homes. Currently only 1% of care homes are considered IG compliant.  A timely breakthrough with a new and improved Information Governance toolkit by NHS Digital is a major development. Completion of the toolkit is paving the way for more care homes to move away from paper notes and outdated processes, and venture in to the digital world. This will improve efficiency, patient empowerment and join up communication channels between care homes and NHS health care providers through CMC. 


The Health Innovation Network (the Academic Health Science Network (AHSN) for south London) is working with CMC to make it a reality for many frail & vulnerable residents living in care homes to firstly have a CMC record – and crucially have it accessible by the care home team.  We are starting by working with two nursing homes, Wandsworth CCG, care home staff, Marie Curie and the care home GP to implement CMC. Innovative models have been developed to allow care home staff access to CMC in both Information Governance (IG) compliant and non-IG compliant care homes. 

PHASE ONE: The pilot study is phase one of the project which will cost £3000. Funding will pay for two Marie Curie nurses to provide training and support to the care home staff, IT equipment and promotional material needed to engage the residents and their families. This will equate to 90 residents across 2 nursing homes having a high quality CMC record created. The records will then be reviewed and updated as needed by the care home GP and care home staff.   

PHASE TWO: Completion and learning from this pilot will inform our approach on how we support other care homes (nursing and residential) to adopt and embed CMC in a high quality, cost-efficient way. £27,000 will be used to support further care homes to engage in the project to successfully embed CMC. Modifications of the model, variations in the approach to be taken and financial support required by each care home will be dependent on the type of care home, local authority, CCG support, resources required, training needs and Information Governance compliance levels. The ambition is to support at least 12 care homes in South London, approximately 540 residents.

Alongside this work, we will develop an effective and accessible “Peer Support” network for care home staff, managers and stake holders to continue the momentum behind embedding CMC within the care home sector.


Feedback from the care home staff, residents and their families will be collected to monitor the experience for those involved. We will learn what worked well and what can be developed to continually improve the experience for our care home residents. Quantitative data will be collected to measure the number of CMC records being completed through the project.


Your support to secure Q funding is essential for CMC to be embedded across the care home sector and give these residents a platform to have their wishes heard.  We require £30,00 to deliver this project in support of training, project management and measurement. This exciting project is pushing the boundaries, working to address the blockers and barriers (both large and small) and deliver quality improvement between health and social care. We intend to demonstrate that care homes CAN be revolutionised and inspire much needed change across the whole care home sector.

How you can contribute

  • Please support this work to give care home residents a voice and help support integrated working between health and social care
  • Any ideas to develop and strengthen the project are welcomed. You can also email any thoughts to

Reviewer feedback

This is a great project because…

It's a well developed project focusing on the care home sector with emphasis on people as much as the potential of technology. It's got scale and support from organisations to help it deliver.

By the time of the event we encourage the project team to think more about…

Developing the plans further in partnership with care home staff and connecting more with other initiatives in similar territory. Think more about how this project could draw from the expertise of the Q community and how learning will be shared with Q. 


  1. Guest

    Wasim Baqir 3 years, 5 months ago

    Great that this project was shortlisted; congrats. Please do get in touch if you are planning anything specific about medicines choices, esp at end of life. Good luck. :)

  2. A couple of initial ideas: I'm sure that some process mapping around the CMC IT application would help initial users of the system. A process map for the different uses for the CMC care plan would help people to appreciate its value. Please let me know what I can do to help. Regards Tom

  3. Congratulations for getting shortlisted, think this is a fantastic idea and we’d been keen to support this as a wider partner through the London Enhanced Health in Care Homes Programme. This is a workstream within Healthy London Partnership’s Urgent and Emergency Care Programme and we are already working closely with the Health Innovation Network. We can also link in with the Medication Optimisation work that Wasim has mentioned as we are supporting this across London too and through the wider London network. Please don’t hesitate to get in touch to discuss further.

    Kind Regards


  4. Great project. I wonder if this also covers decisions about medicines at the end of life. Many residents remain on inappropriate medicines and some don't get timely access of EOL meds. By understanding residents wishes about medicines and involving them in decisions, we can help reduce risk.


    1. Thank you for this great point. This is definitely something I will look further into to see how this project can link in/support EOL care and medication management as a secondary focus. The more benefits gained and issues addressed through the project the better.

  5. Great project. I would be pleased to do any process mapping (visualization) for your project if it would help in training and implementation. Regards Tom

    1. That would great if you have the time. It's a great suggestion and I agree a process map would be a great way to visualise the project

  6. This sounds great - though I wonder if you can tweak it a bit by adding in 'one-page profiles', of residents and of staff - to help make it even more person-centered...?

    ** Here's an example of a one-page profile of a person at the end of their life:

    ** Here's an example of a one-page profile of a health worker:

    Two birds with one stone...? ;-)


    1. Thank you for this suggestion Matthew. That's a great idea. I will be incorporating one page profiles going forward

  7. This makes such a lot of sense to me. I think it it sounds like you've done enough work already to be looking at Scaling Up rather than this smaller scale funding but its such an important area to work on I'm happy to support it.

    1. Thank you for your support. There is definitely potential to scale up and an area that greatly needs to be addressed to improve patient outcomes and joined up care. This will also support the national deterioration workstream within the care home sector

Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.