A disproportionate number of unscheduled admissions come from care homes – mostly for end-of-life care, falls and infections or a sudden deterioration in the absence of a care plan.
At my surgery, we have tackled this with a dedicated care home team supported financially by a LES that allows us to do all out-of-hours calls 24 hours a day, 365 days a year on a rota with a GP always available for advice by phone. We are supported by a healthcare assistant in the practice, a pharmacist, the CCG Macmillan nurses and three CCG advanced nurse practitioners.
The local geriatricians will also do a visit within 72 hours for routine cases or 24 hours if cases are urgent.
But there are aspects of our care we believe can be carried out by any practice with minimal workload implications.
The most important ways to prevent admissions without extra funding are:
- completed DNARs
- doing a weekly round, which will save time on unscheduled visits
- trying to build up a population in a home, rather than clinging to a patient in a home you rarely visit.
Ward rounds
Each home has a lead GP who does a regular round, varying from twice weekly to fortnightly, according to size of the care home and turnover.
Regular ward rounds allow us to get to know the staff, which builds up trust and stops them asking for multiple visits for minor problems that could wait or be dealt with over the telephone. They get used to calling us rather than 999.
Difficulties arise when we see poor practice in the home – for example bruising that could be due to rough handling. We help as much as we can to improve standards, but sometimes we have to approach the CCG.
Patient records
Accurate patient records are vital. We currently use software that gives us a complete record on a laptop but are moving to EMISweb, which we hope will further enhance the records. The care homes fax an information sheet to us on admission, this is followed by a faxed summary from the previous GP and then the notes are summarised. All letters are scanned on to the system. Records are updated daily to ensure accuracy.
Clinical protocols
We have protocols for falls and some medical conditions. Our protocol on UTIs gives care home staff pointers to identify a potential infection and advises on early management – such as giving fluids and keeping a fluid balance chart. It also tells them when to contact the GP – aiming to avoid the need for admission.
Medication reviews
Our attached pharmacist does regular medication reviews – working through all residents and then discussing their medication with the GP who covers the home – as well as other projects, such as cutting the use of antipsychotics.
Do not attempt resuscitation
We work hard with homes to establish DNAR forms and discuss them with residents and their families. It is vital these forms include an agreed preferred place of care, otherwise staff may be too nervous to do anything but call an ambulance when there is deterioration.
Some 50% of our residents have a dementia diagnosis – although in reality this probably should be 60%. Patients who have dementia often deteriorate in hospital so we are making an effort to get DNAR forms for them when appropriate.
Working with the ambulance service and A&E
We are meeting regularly with the hospital ambulance liaison officer to reduce the number of residents taken to hospital. They are trialling a falls paramedic to see residents and offer reassurance. We are working to allow ambulance crews to hand over to the GP on call where appropriate. Many of these patients will not need an immediate visit and can be followed up later. We have the luxury of the records, which the ambulance crews do not.
We are also working with A&E staff to get them to contact the GP on call and discuss whether to send the resident back to the home rather than admit them.
Talking to relatives
One of the most time-consuming aspects of our work is talking to the relatives of residents. It is vital to keep them informed and get their assistance. Some relatives have very unrealistic expectations and many have high levels of guilt.
Time spent talking to them is well rewarded and mandatory where DNARs are concerned. There will always be some relatives who insist on admission to hospital and who complain about treatment – it is part of our job to deal with this.
My experience is that it is far better to have dedicated time for care homes. If you have enough homes and residents, you can have dedicated staff for the role. I also believe that it is vital that we provide out-of-hours cover.
Dr Nick Plant is a GP in Kingswinford, Birmingham
