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Enabling End of Life Advance Plans for residents in care homes to be securely shared with their networks

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NHS Trafford identified the following needs:

  • To increase the number of Advance Plans shared in Trafford which will improve the number of people dying in their preferred place
  • To enable the wider community beyond healthcare providers to participate in Advance Planning including care home staff and volunteer agencies.
  • To effectively support engagement with families and personal networks in End Of Life planning through wider access to the informatio

The system enables the Advance Plans to be securely sent through to the GP and onward into the wider community as required.


The ability to digitally capture Advance Plan in care homes and the wider community to provide a consistent and accurate format across the economy.  The system would need to include educational prompts, national codes where applicable, and the facility to share this plan with other people in the resident’s network to improve the communication with residents and their families.


Intelesant was commissioned to develop and provide it’s digital platform to care homes across Trafford and support homes to use the system effectively. Intelesant’s Howz system comprises a web portal designed for tablet devices providing access to the full range of assessment and planning tools with integrated education, and a Howz app to enable selected elements from the profile to be accessed easily on a mobile device by the individual or those within their approved network.

The core set of features for the platform can be adapted for different use cases:

  • Demographics.  Patient name, contact details, sensitive data, family and carers and contact details;
  • Planning.  For example in the End Of Life case Lasting Powers of Attorney, Decisions to Refuse Treatment, Decisions not to Resuscitate, Advance Plan such as preferred place of care and death;
  • Sharing.  Manage consent and capacity; item by item controlled access to family and carers and organisations;  secure and medically coded email updates to GP’s over the NHS N3 network;
  • Compliance.  Activity and history audit log, compliant with NHS information governance level 2.0 (e.g. encryption, 2 factor authentication, email), compliant with NHS EPaCCS (Electronic Palliative Care Co-ordination System) requirements.

Next steps

We created a clinical working group with the lead nurse from EOL trained care home, the training lead nurse from the local hospice who delivers the care home EOL care education programme, and the EOL lead from the CCG.  Together this team worked on the content and flow of the information creating a user friendly system that met the needs of the carers and supported the sharing of the Advance Plans.

We then worked with local GP practices to ensure the information could be easily accessed.

We are now working to expand the number of care homes using the system and benefitting from the family access page.  We are now developing an Advance Plan system that will be open to all residents in Trafford enabling them to record and share their own record with those people who are important to them.  For people with dementia and their carers we are working with local carers and Trafford Carers Centre to develop the functions and ensure that they are able to make best use of the system along the full timeline of the disease.