The project, running for 8-9 years, has developed;
A tool to assist patients to record their wishes for their care in their GP record. The My Wishes leaflet. Ideally used alongside AgeUK's "Let's talk about death and dying" resources.
Tools to assist General Practice teams:
to record patient Wishes & Expectations for their care, Treatment Escalation Plans, Frailty assessment, MDT & GSF meeting notes and End of Life preferences for care. The Future Planning template for EMISweb and SystmONE (General Practice and Community Trust versions available). Currently version 4.3 following 8 years of iteration.
with staff education "how to" guides. We recently completed eLearning resources for SystmONE community use, have completed RiO community eLearning and will be using both of these eLearning sets to develop eLearning for primary care EMIS & SystmONE practices.
3 videos. Two for patient and family use, suitable for use on practice reception video loops. And, a staff introductory video, kindly narrated by Hugh Bonneville, which kicks off each of our eLearning sets.
awareness raising posters for waiting rooms and other public areas. Also, banners for conference attendance.
to safely transfer End of Life patients from oral to subcutaneous medications. The EoL Medication Worksheet for EMIS Web & SystmONE.
the Future Care Plan. A self populating word file to print from EMIS and SystmONE that takes patient diagnoses and information from the wider patient GP record and Future Planning template and provides a paper clinical summary that can be used by patients as they wish. Or in those cases where ambulance crews are unable to access the Summary Care or Local Care Record, then the Future Care Plan provides a summary for use in emergencies.
"I Have A Plan" fridge magnets to be given with the Future Care Plan. When used alongside the Lions charity Message in a Bottle this highlights the presence of a Future Care Plan in the property. Ideally, the Care Plan will be kept in community nursing team folders. However, some people may prefer to place the whole care plan on the fridge, though additional magnets are likely to be required. And, fitted kitchens with wooden doors over a hidden fridge present a further attachment challenge - think double sided sticky tape!!
The Future Planning MiQuest report which previously produced a list of practice patients for GSF meetings can no longer be relied upon following the partial switch of EMIS and SystmONE to SNoMED CT coding. Any practice wanting to develop local reports is welcome to access the full Future Planning coding set to help with this task.
Population Health Management reports are being developed by Hampshire & Isle of Wight ICB to support the implementation of an ICS wide, ePaCCS (electronic Palliative Care Co-ordination System) or better still an Advance Care Planning solution which forms one manageable step in Proactive Case Management supporting the 2023-24 Proactive Care DES. Any ICS wishing to use the database queries developed may gain access to these and all other resources via our contact pages.
Why Future Plan?
Many community clinical teams and all General Practitioners have held patient records on computer for years. Most use different systems and as a result GPs often cannot see community notes, district nurses cannot see GP records and, more worryingly, emergency teams do not always have access to up to date information about the patients they are treating. The Future Planning Template has been designed by GPs, Palliative Medicine clinicians and CCG staff to collect vital patient information in one place within the patients SystmONE or EMIS GP record.
What does the template achieve?
All template information is automatically uploaded to the Summary Care Record - accessible by Acute Care Teams across England.
Local Care Records - All information automatically uploaded to the Care and Health Information Exchange (CHIE). Where, in 2023-24, they will be visible in care plans using the Orion upgraded CHIE portal.
A standard way of documenting patient preferences for Future Care Planning or Treatment Escalation Plans
Ability to printout a Future Care Plan for patients
Supports general practice Gold Standard Framework meetings
Supports achievement of at least 2 RCGP Daffodil Standards
Will support the 2023-24 Frailty Proactive Care DES
Tick box "GSF template" speeds completion during meetings
Somewhere to record that all important GP, specialist or MDT approval for community teams to undertake VoD