Advance care planning (Coordinate my care)

Identification of people who might be in their last year of life enables us to have a pre-emptive compassionate advance care planning discussion and ensure the best possible support for patients and avoid inappropriate conveyancing to hospitals.

To help explain more about Advance Care Planning, we have created a patient focused guide

Where possible, GPs should be carrying out anticipatory care planning for vulnerable populations (frail elderly / care home residents, etc.), using Coordinate My Care (CMC).  There is work underway at a national and local level to help identify who would benefit most from a care plan, but in the meantime, please commence updating care plans for your vulnerable/at risk/frail patient cohorts.

The following teams now have the ability to support with editing and creating plans:

  • GPs working in out of hours settings including primary care hub GPs
  • Paradoc GPs
  • Medical consultants on call
  • Hospice staff

CMC Resources

CMC have produced a short video on how to create an alert for patients with existing CMC records.

CMC have produced a 5 minute video on how to create a CMC plan

The GP that the patient is currently registered to will remain the holder of the CMC plan and will be required to complete a desktop review and approve the document before it becomes live or ‘published’ (available for LAS and other urgent care clinicians to see).

Co-ordinate my care (CMC) have released a resource pack to support increased use of CMC. 

The resource pack contains guidance to make CMC easier to use:

  • How to create rapid plans for people at high risk;
  • How to rapidly update records for people at high risk;
  • How can we increase the number of CMC plans that are viewed?

The pack also includes appendices on primary care and community respiratory resources; identification of those at risk; READ and SNOMED codes relating to resuscitation; CMC practice list functionality; batch log-in requests and CMC Urgent Care Summaries.

CMC has issued some guidance to GPs with a suggested text message to send to patients.

Joining CMC

For Health and Social Care teams wishing to start using the Coordinate my Care (CMC) service, you need to follow these steps

Also Care homes will be able to gain CMC log ins quite quickly. Please get in touch for more information (details are below) 

For more information

Contact CMC on 020 7811 8513 (open to patients Monday to Friday, 9am-5pm) or email 

For further details, visit the CMC website 

 End of Life Care in Frailty

The British Geriatrics Society has produced guidance to support clinicians and others in considering the needs of, and providing high quality care for, frail older people as they move towards the end of their lives.  It aims to prompt and support timely discussions about preferences of car, ideally at a time which facilitates the input of the older person themselves.


Updated: 28/05/2020