GP partner Dr Pipin Singh outlines how to run a care home service both effectively and efficiently
Local enhanced
services around enhanced healthcare in residential and nursing homes are
increasingly being offered.
Recent evidence from
the British Geriatrics Society suggests that the number of emergency admissions
can be reduced by proactive care to nursing and residential home residents.
More proactive care
from GPs and other members of the primary care workforce is therefore being
encouraged to help improve care planning, medicines management and
communication around end of life care.
A lot of practices
will look after one or more care homes and may well be undertaking this sort of
work already. A local enhanced service may allow you to streamline this work.
Aims and objectives
One of the main
reasons for enhanced care home work is reducing avoidable and unnecessary
admissions, including having care planning discussions and writing health care
plans. Specific requirements will vary somewhat but will typically be to:
- Offer regular clinical review of patients
within the home in a structured fashion
- Reduce clinical workload from the care home
throughout the week
- Ensure new admissions have a
patient-centred plan within 28 days of arrival
- Work closely with pharmacists to perform
medication reviews at least once a year
- Identify those who are approaching end of
life and manage this accordingly and proactively in conjunction with the
patient and their next of kin/advocate
- Ensure patients discharged from hospital
are reviewed promptly after discharge
- Ensure out-of-hours providers are aware of
more complex cases or patients approaching end of life where DNACPRs and
emergency health care plans are in place
- Ensure clinical notes are appropriately
coded with any relevant documentation and if appropriate the patient is on your
palliative care register.
How to set up your
procedures
Identify your lead
GP or GPs for the process. Having one GP per home will enhance the continuity
of the process, which should ultimately yield savings through optimal medicines
use and reduced unscheduled admissions.
In our case it requires
one session of GP time per week; costs of this will vary depending on whether
it is performed by a salaried or partner. You can also consider using advanced
nurse practitioners, if applicable to your practice and it is felt that their
skillset will be appropriate.
Considerations for how
to run your ward round:
- How
frequently you will carry out ward rounds, eg, weekly
- Time
allocated to each ward round – make sure this is in line with local service
specification requirements.
- Whether
you intend to see all the patients or only patients of concern. The lead GP can
then decide how the ward round should take place in conjunction with the
nursing or caring team. The most efficient way is only to review patients of
concern, but make this clear to the care home. You should only need one or at
most two GPs.
- Provide
the care home team with a check list of what should be ready for your arrival
before the ward round, eg, a requirement that acutely unwell patients have
observations recorded, or that DNACPRs or emergency health care plans are ready
for viewing.
- Decide
whether you will see relatives on the ward round or would prefer to see them at
a separate time, eg, at a separate surgery appointment via telephone or face to
face. Ensure this is made clear from the start.
- Clinical
notes will take time to document so you may wish to use a CCG provided laptop
with remote access if this suits your practice. That way you can also issue/change
medications while on the ward round. I usually review notes before visiting and
then allow around 90 minutes to type up notes and action any work needed, eg,
referral or medication changes, straight after the ward round.
- If you
involve a pharmacist, ensure the GP lead discusses cases with the pharmacist
after each ward round, eg, any medication changes. Consider a joint ward round
with the pharmacist very six months.
Making the most of
a pharmacist
- If you
employ an in-house pharmacist, consider using their skills to undertake the
medication reviews
- If
not, is there any pharmacy support via your primary care network?
- Decide
how often this should happen
- How
should any important medication reviews be discussed with you? Can you allocate
time after your ward round?
- Can
the pharmacist review all discharge medication changes?
- Ensure
that communication between you and your pharmacist about the care home patients
is ongoing and regular, particularly if you’re not seeing the patients
together.
Care plans and
DNACPR orders
Ensure a clear plan
for who will write the care plans and DNACPRs.
- Decide
if this will be GP or nurse-led. Residential homes usually require more
clinical input to support carers, eg, to complete care plans and DNACPRs, than
nursing homes where nurse leads often skilled in these discussions.
- When
the plan is complete, ensure this is reviewed by the lead GP, signed and
scanned into the clinical record then returned to the home. The lead GP may
wish to amend the care plan also. The same applies to the DNACPR.
- How
often should the care plans be reviewed? It may be reasonable to review this
annually as with the DNACPRs.
- The
lead GP may need to get involved with the DNACPR /EHCP discussions depending on
the skill set of the staff at the care home. You may consider ways to upskill
the carers to have discussions so that GPs can be involved mainly in more
complex cases. Most nursing staff in nursing homes are comfortable in having
these discussions around resuscitation and care planning for common scenarios –
for example managing infection, hydration, nutrition, falls and serious fractures.
Out of hours
notification
How surgeries carry
this out will vary.
But whatever the
system, ensure out-of-hours providers are informed of patients where you feel
that problems may arise – whether due to end of life or other reasons. This
will be via email, fax or completion of any online reporting systems.
This will hopefully
allow for appropriate admissions only and ensure you can meet your requirements
for any avoidable admissions targets.
End of life care
Enhanced services will
often require you to demonstrate you communicate effectively to the nursing
staff/carers and family if you feel a patient is approaching end of life.
- Ensure
your assigned home is skilled in managing patients approaching the end of life.
- Ensure
they know how to access anticipatory medications quickly.
- Set up
prescribing mechanisms on your clinical system to allow the medications to be
prescribed quickly. Ideally you would discuss this with your in-house
pharmacist or network pharmacist.
- Ensure
appropriate mechanisms are in place to notify out-of-hours settings so
patients’ comfort and dignity is maintained.
Related practice
work
Delivering
enhanced care home services can allow you to manage patients more effectively
in other aspects of your contractual work, such as QOF and immunisations.
For
example, as part of your processes ensure patients are exception reported from
certain targets where recommendations for blood tests or scans are
inappropriate. Also make sure you have a
robust process for care home patients’ flu and pneumococcal jabs.
Summary
- Ensure
you provide the care home staff with a checklist of things you would like done
prior to your visit to save some time.
- Consider
upskilling the care home team to prepare the EHCPs and have DNACPR discussions.
- Ensure
you communicate regularly with the pharmacist assigned to your care home, in
particular so you are aware of any significant medication changes they make and
vice versa.
- It is
crucial to make families aware of how they can communicate with you.
- Keep
out of hours services updated about needs and wishes of complex patients or
patients approaching the end of life.
- Ensure
the care home team knows who they can refer to directly without having to
involve the GP, for example the dietitian, occupation therapist, dentist etc.
Dr Pipin Singh is a
GP partner and trainer in Wallsend, Tyne and Wear
