The Co-ordinated Care Cohort is a concept created in County Durham 2017-19, principally to help in the management of frail elderly people whilst creating trying to prevent the need for multiple care plans and pathways e.g. dementia, frailty, palliative care.
Patients in the Co-ordinated Care (CC) cohort are patient who will tend to benefit from:
- Prioritisation of quality of life over length of life
- Greater emphasis on holistic care rather than single disease management
- Avoidance of iatrogenic harm, especially polypharmacy
- Enhanced interdisciplinary working
- Better communication between involved care teams
- Advanced care planning
The CC cohort includes the following people by default
- Patients with Frailty
- Patients with Dementia
- Patients on the Palliative Care list
Most patients on the CC list are frail and elderly.
Patients who are not in one of the categories above can be added to the cohort by adding the following code:
Referral to the community multidisciplinary team
Patients can be removed from the cohort (e.g. a younger fit patient with early onset dementia) by adding:
Discharge from the community multidisciplinary team
Identifying Patients in the Cohort
The cohort is automatically kept up to date if the organisation maintains its frailty, dementia and palliative care registers. More information on identifying frail patients can be found here.
The search shown below, found in the CDRC > Care Planning folder, will identify patient currently in your coordinated care cohort:

Patients in the cohort will have the following patient status alert (icon) if this has been enabled at your unit.

Coordinated Care Cohort Template
The Coordinated Care template provides an overview of key information about the patient with relevant links. This also provides a place to record MDT discussions. More details about the template and resources can be found at Care Planning – Introduction
![Coordinated Care
Summary
Add Recall (Coord Care)
Discussion
MDT Meeting
Finished by
FORBES, Gareth (Dr) (General Medical Practitioner) [18 Jul 2018 15:08]
Coordinated Care Summary
Coordinated Care Summary
Bedbound with parkinsons
This patient is in the virtual ward OR GSF Amber or Red OR End of life
Comprehensive Geriatric Assessment
" Change SCR Consent
" Falls
" Medication Review
Cog Screen
MUST
Depression Anxiety Sc
Resuscitation
ppc
PPD
Carers
SCR Additonal Information NOT shared - preference no
GMS Falls code RECORDED (last 12 months)
No record of med review in last 11m
PATIENT HAS POTENTIAL MEDICATION SAFETY ISSUE
Dementia
Fraity
Housing
Palliative Care
14 2020
14 2020
14 2020
Referral to memory clinic (Xadua)
Malnutrition universal scr„ 2
Depression screening using
NOT FOR ATTEMPTED CPR
Preferred place of care - care home
Preferred place of death - home
Has EHCP
No Record of ADRT
HAS A CARER
LPAAMCADOLS
Safeguarding
NOT Diagnosed with DEMENTIA
MILD FRAILTY - Review within 1 lm
NOT housebound
on PALLIATIVE CARE REGISTER - Amber
No record of anxiety or depressive disorder
HAS LP ATTORNEY FOR WELFARE
No record of 'MCA
NO record affairs under court jurisdiction
Not currently recorded as subject to a DOLS Ord.
NO record of current safeguarding concern](https://cdrc.nhs.uk/wp-content/uploads/2022/10/image-134.png)
Co-ordinated Care Review
A simple system is available to allow flexible planned review of patients in the cohort. The template above will show if the patient has a Palliative Care or Coordinated Care recall.
The following reports, found in the CDRC > Care Planning folder, will identify patients who don’t have one of those two recalls and patients who are due for recall respectively. This allows teams to plan when each patient should be reviewed, with the review period being based on clinical need:
