EPaCCS: Information for clinicians

• To improve the quality of care for people near the end of life
• Information about a person’s care needs and wishes to be shared across multiple organisations
• Having personal choices, priorities and goals for care recorded and easily accessible
• Helps prevent delays in care or avoid unplanned and unwanted urgent care or hospital admission

Adults with any life-limiting condition(s) or illness(es) who are deemed more likely to be nearing End of life.

This includes any person with life limiting/ incurable progressive diseases, including frailty and dementia. Other people that can be added to the register include those with complex, or highly unstable conditions or patients expressing clear choices and priorities for their care for any reason.

All professionals/staff across all providers in mid and south Essex can add a person to an EPaCCS register, including:

• The three acute hospital sites of MSEFT
• Primary care, community provider nursing and therapies integrated teams
• Community dementia teams, mental health teams
• Community hospitals, hospices, out of hours 111 providers, emergency services
• Social care professionals and domiciliary care providers including care homes

For SystmOne users

You can add a person via a direct referral in SystmOne to the specific EPaCCS register based on where the person is currently living:

• The EPUT EPaCCS register for residents in South-East Essex
• The St Luke’s EPaCCS register for residents in the Basildon Brentwood or Thurrock areas
• The Provide EPaCCS register for residents living in Mid Essex

Many direct quick referral links have already been built into pre-existing SystmOne assessment templates that multiple providers have access to. For example, FrEDA (Frailty End of Life Dementia Assessment SystmOne care coordination template) has a quick referral button to your local EPaCCS register on the End-of-life page and within the electronic referral pages. 

Staff in MSEFT Specialist Palliative Care Teams should use their specific Palliative Care SystmOne template which has the quick referral button to all three EPaCCS registers.

Non-SystmOne users

If you do not have access to SystmOne – then you can add a person to a register by email:

• South East Essex (EPUT): communitypalliative.careservices@nhs.net
• Basildon, Brentwood, and Thurrock (St Luke’s): stlukes.oneresponse@nhs.net
• Mid Essex (Provide): provide.ccc@nhs.net 

1. Explain to the person the benefits of EPaCCs. Set out how being added to the register will allow any health professional to access information about their choices, wishes and goals for care. Explain how this information will allow health professionals to better priorities and consider care options best in line with the details recorded on the register.
   N.B. Provision of a MSE EPaCCS leaflet is currently being developed and will be available on the MSE ICB website.
2. Add key information on the nature of the person’s life limiting condition(s). For example, do they have dementia, frailty, heart failure, respiratory disease, cancer etc.
3. Include information on the person’s preferences. At this point you can add any information you have on the personal preferences, choices, and goals of the person. This can include:

• preferred place of care
• preferred place of death
• DNACPR status
• if an Advance Care Plan ACP (PEACE) document is in place and current estimated GSF (Gold Standard Framework) stage status. 

The example below shows how this information appears on the home screen of the person SystmOne record. This information comes under high priority reminders for quicker and easier visibility so that any professional can see it when they open the person’s record. Seeing this denotes that a person is already on an EPaCCS SystmOne register platform.