Clinical Digital Resource Collaborative

Designed and developed in the North East and North Cumbria by local GPs

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Co-ordinated Care

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. 

cc CC Coordinated Care In coordinated care cohort
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
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: