Effective care planning for our most vulnerable patients ensures patient wishes are made central to their care, reduces carer stress, facilitates tracking of care and averts urgent care crisis.

I-CARE & Share is a programme across Cheshire and Merseyside seeking to improve personalised care planning. I-CARE & Share combines an EMIS template, which requires installation on respective GP EMIS systems with a mergeable Personalised Care Plan (PCP) containing the relevant palliative care codes to support sharing of information. The form has been specifically designed to be used as an electronic tool within EMIS and equivalent systems to enable sharing of information. Once completed electronically it may be printed to provide patient and carer copies.

The programme is anchored through its acronym:

I – Identify patients at risk of futile hospital admission

C – Communicate sensitively with patients, family and carers

A – Anticipatory Care Plan agreed

R – Resuscitation decision put in place

E – Escalation Plan agreed

S – Share with key providers

The programme seeks to strengthen each aspect of the above. This includes the standardisation of a Cheshire and Merseyside personalised care planning package that meets patient, clinician, digital and organisational requirements to ensure personalised care planning is robust and effective. This currently includes:

• I-CARE & Share personalised care planning templates (EMIS and System One) for codes capture
• I-CARE & Share Personalised Care Plan
• North West Unified Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) form

When used as recommended the I-CARE & Share package meets the requirements for:

• Gold standard End of Life care
• Palliative care
• Primary Care Network DES for care home residents
• Complex patients with long term conditions
• Use by GPs, nurses, pharmacists and care coordinators
• Business intelligence capture
• Data sharing via shared and summary care record
• Electronic Palliative Care Coordination System (EPaCCS)

The Personalised Care Plan once completed electronically should be shared with the patient, carers, GP-out-of-hours service and Ambulance Service.

More information on the  Cheshire & Merseyside ICB I-CARE & Share package can be found here.

I-CARE & Share resources 

For support within your Place please contact your local Clinical Lead for Palliative and End of Life Care (PEOLC).

Cheshire and Merseyside ICB Lead:  peter.chamberlain@cheshireandmerseyside.nhs.uk

For signposting support from the PEoLC Network: Carmel Wiseman, Clinical Network Programme Manager – carmel.wiseman@nhs.net