Coordinating multiple services involved in patient’s care, outside of the Mid and South Essex Region, using Shared Care Record

A Clinical Nurse Specialist, Steven Hart, from St Luke’s Hospice has demonstrated how the Shared Care Record supported multi-agency working, across counties for a palliative care patient.

The challenge

A patient was receiving specialist palliative care and support from a local hospice and was living in the catchment area of Mid and South Essex. However, all of her oncology treatment and care was from hospitals and Centre’s within the central London region. This identified some challenges, in relation to utilising different systems, and having some delay in accessing up-to-date; clinic letters, management plans, admission information, scan/blood results and if any upcoming appointments had been made.

During the time caring for this patient, there had been some delays in providing the gold-standard, holistic based care, due to having to either wait for hospitals, outside of the Mid and South Essex region, to send information to the General Practitioner to be uploaded to the locally used system, or if the patient obtained a copy and sent directly to the Hospice. Whilst there was no deterioration in their physical health symptoms, due to waiting for this information, it was a challenge, in order to best support the patient at that specific time, ensuring we was working collaboratively with her primary oncology team. In order, to try and keep the information being shared cohesively between counties, emails would be sent, securely, to make enquiries, or request information, relevant to the patients care and management. Whilst this was the only option available at the time, it would involve having to wait for the replies from the specific individual.

Accessing shared information

Since the Shared Care Record has been introduced at St Lukes, it has supported to resolve the challenges faced with patients who live within the local area but have been receiving treatment and support from acute services outside of the Mid and South Essex area. We have now been able to access the Shared Care Record’s Cerner (HIE) link and access her medical information, including recent clinic letters including management plans, laboratory results and radiology results and any future booked appointments.

Impact and outcomes

Using the Shared Care Record helped to:

• It has allowed for enhanced patient-centered care to be practice, ensuring that we are working collaboratively with primary care providers and acute trusts to ensure the best possible goals for the patients are achieved.
• We are now able to see when the patient has upcoming appointments, it allows for better scheduling for when visits are required from the hospice, and to continue Palliative Support within the community setting.
• It has reduced delays with receiving information regarding the patient’s treatment, ensuring the multi-agency work can take place and everyone involved are aware of the most current relevant medical information. It has also reduced the amount of information requests having to be made, as the information is already there.
• It also supported with enhancing the accuracy of decision making, based on the information being obtained direct from the Shared Care Record, allowing for cohesion and the correct approach to patient management, based on current information being provided from the acute services outside of the local area.

The difference it made

The implementation of the Shared Care Record has been critical in allowing for a more streamlined process to obtaining up-to-date medical records for patients. It allows community partners to be well-informed of current plans for the patients care, and allows decisions to be made, in order to continue to support the patient in the community setting.

Steven feels that since the information has been accessible and linking across different acute trusts, community trusts and primary care, it has allowed for improved decision making, with less challenges along the journey, and reduced the number of delays in waiting for replies to information requests. It has ensured that the patient has received timely support and ensuring a consistent approach.