Quality standard

Quality statement 3: Coordinated care

Quality statement 3: Coordinated care

Quality statement

Adults approaching the end of their life receive care that is coordinated between health and social care practitioners within and across different services and organisations. [2011, updated 2021]

Rationale

Adults approaching the end of their life are likely to receive planned and emergency care from a range of services and in a number of settings. Coordination of these services is necessary to ensure that there is a shared understanding of the person's holistic needs and that the person receives end of life care that meets their specific needs and personal preferences. Coordination also leads to care being provided more quickly, as it is needed.

Information sharing across organisations will help to ensure that adults approaching the end of their life do not have to repeatedly provide information that can be shared between services. Coordination will help to ensure that people are not over-burdened with appointments and home visits. Appointments can be reviewed and optimised if possible, for example, coordinating appointments to avoid multiple visits.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.

Some routinely collected national data for these measures has been identified. Where there is no routinely collected national data, some examples of potential data sources have been suggested.

Structure

a) Evidence of local processes to coordinate end of life care.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service specifications and joint working agreements between health and social care. This could include processes to ensure appointments with different specialities are on the same day to avoid the person making repeated visits.

b) Evidence of local arrangements for relevant information about adults approaching the end of their life to be shared with the members of the multipractitioner team involved in their care.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local information-sharing protocols and electronic information-sharing systems.

Process

a) Proportion of adults approaching the end of their life whose advance care plan is shared with the practitioners involved in their care.

Numerator – the number in the denominator whose advance care plan is shared with the practitioners involved in their care.

Denominator – the number of adults approaching the end of their life who have an advance care plan.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local audit of patient records.

b) Proportion of adults approaching the end of their life whose care is coordinated through the multipractitioner team.

Numerator – the number in the denominator whose care is coordinated through the multipractitioner team.

Denominator – the number of adults approaching the end of their life.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local audit of patient records and of multipractitioner team and multidisciplinary team meetings.

Outcome

a) Proportion of adults approaching the end of their life who are cared for in their preferred place.

Numerator: the number in the denominator who are cared for in their preferred place.

Denominator: the number of adults approaching the end of their life.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, through face-to-face discussions with adults approaching the end of their life and their carers, local patient and carer experience surveys and bereavement surveys.

b) Proportion of adults who were identified as approaching the end of their life who had an unplanned admission to hospital.

Numerator: the number in the denominator who had an unplanned admission to hospital.

Denominator: the number of adults identified as approaching the end of their life.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, through local audit of hospital admissions data and patient records, local patient and carer experience surveys and bereavement surveys.

c) Proportion of adults who were identified as approaching the end of their life who died in their preferred place.

Numerator: the number in the denominator who died in their preferred place.

Denominator: the number of adults identified as approaching the end of their life who have died.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local audit of patient records, local carer experience surveys and bereavement surveys. The National Audit of Care at the End of Life measures the number of people who have a documented preferred place of death on their final admission.

What the quality statement means for different audiences

Service providers (such as care homes, hospices, ambulance services, mental health care, social care, community care, primary care, secondary care and tertiary care) ensure that electronic information-sharing systems are in place so that all practitioners providing care can access up-to-date records and advance care plans. They also ensure that systems are in place so that the multipractitioner team can coordinate care, including coordinating appointments, for people who are approaching the end of their life.

Health and social care practitioners (such as care home staff, social workers, mental health clinicians, occupational therapists, pharmacists, paramedics, GPs, specialists and nurses) work with other members of the multipractitioner team to coordinate the care of adults who are approaching the end of their life. They ensure that all relevant information is added to the person's record and advance care plan so that it can be accessed by other practitioners involved in the person's care when needed.

Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that the services they commission have electronic information-sharing systems in place to allow all practitioners providing care to access the records of adults approaching the end of their life. This can be done, for example, by enabling existing IT systems or by introducing a specific system such as the electronic palliative care coordination system (EPaCCS). They also ensure that the services provide multipractitioner team care and care coordination for adults approaching the end of their life.

Adults approaching the end of their life are cared for by a team of health and social care practitioners who work together to coordinate their care and make sure that important information is passed on. This means that the person does not need to keep providing the same information to different people caring for them or attend several appointments on different days that could take place in one visit.

Source guidance

End of life care for adults: service delivery. NICE guideline NG142 (2019), recommendation 1.8.1

Definitions of terms used in this quality statement

Adults approaching the end of life

Adults in the final weeks and months of life, although for people with some conditions, this could be months or years.

This includes people with:

  • advanced, progressive, incurable conditions

  • general frailty and coexisting conditions that mean they are at increased risk of dying within the next 12 months

  • existing conditions if they are at risk of dying from a sudden acute crisis in their condition

  • life-threatening acute conditions caused by sudden catastrophic events.

[NICE's guideline on end of life care for adults, terms used in this guideline]

Carer

A carer is someone who helps another person, usually a relative, partner or friend, in their day-to-day life. This term does not refer to someone who provides care professionally or through a voluntary organisation. A young carer is aged under 18. [NICE's guideline on end of life care for adults]

Multipractitioner team

A multipractitioner team is a group of practitioners from different clinical professions, disciplines, organisations and agencies who together make decisions on the recommended treatment for individual patients.

[NICE's guideline on end of life care for adults, terms used in this guideline]