Neuro LTC: Online integrated care plan

Complex long-term neurological conditions often require the input of several health care teams across primary and secondary care settings. Personalised care plans allow for integrated care planning and improved communication between the different health care professional teams.

The proportion of people with long-term neurological conditions who feel involved in making choices about their health services, who are offered a care plan, or who feel that their health care professionals work well together, is declining. In the 2015 GP survey, people with neurological problems were less likely to feel they were adequately supported than people with other long-term conditions.

This project, led by University Hospital Southampton NHS Foundation Trust, has created the opportunity for personalised, online integrated care plans for 500 patients living with long-term neurological conditions.

Patients were recruited by their health care teams based in both hospital clinics and community neurology care services.

The project used the Trust’s existing patient online service (My Medical Record – myMR) as a platform to allow health care professionals and patients to create, access and manage individual care plans. The platform interfaces with hospital and community systems to automatically upload relevant documents, and patients are encouraged to add personal information and preferences. In addition, patients are encouraged to complete online health surveys to identify changes in health outcomes. In time, this will improve communication and care planning between multidisciplinary care teams and patients.

In the initial project, patients and staff quickly engaged with the functionality of the platform and gave positive feedback that the platform is useful to them.

The project is now being scaled up across the Wessex region (Hampshire, Isle of Wight and Dorset) to support all patients with a neurological condition to access MyMR, including patients with young-onset forms of dementia and Huntington’s disease. An evidence base will also be developed for the scale of generic digital platforms across national neurological services.

Contact information

For more information about this project, please contact Dr Christopher Kipps, Consultant Neurologist and Honorary Clinical Lecturer, University Hospital Southampton NHS Foundation Trust.