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Clinical directors and care home leads joined editor Victoria Vaughan to discuss the progress made during the past year through the enhanced health in care homes service
Dr Amit Bhardwaj, care home lead GP, Harpenden PCN, Hertfordshire
Dr Binodh Chathanath, clinical director for Bexhill PCN, East Sussex
Dr Katharine Bhatt, nhanced health in care homes and frailty clinical facilitator, Torbay and South Devon Foundation Trust
Dr Dan Bunstone, clinical director, Warrington Innovation Network PCN, Cheshire
Dr Zoe Archer, care home lead, Hastings and St Leonard’s PCN, East Sussex
Sam Johnson, care home programme manager, Central and West London
Victoria: Pulse PCN first discussed this service in the spring 2021 roundtable. Then the challenges were how to link the service with work already happening. There was a disconnect between the service demands and patient care. More than two years on, how is it now working in your areas?
Katharine In Torbay, we have a relatively aged population and there are about 87 care homes and almost 2,000 care home beds. Three PCNs have collaborated and deliver enhanced health in care homes (EHCH) through one team using staff from all three PCNs so GPs work on a rotational basis. And we have pharmacy cover, paramedic support and a nurse as well.
We had an acute care visiting service in place before and we have bolted on to that existing service. Doing it at scale has given us some benefits in terms of economies. We have access to wider hours of support than before. We do weekly home rounds and signpost to the most appropriate member of the clinical team.
From a system perspective, I was previously the clinical lead for three PCNs, but we have eight PCNs in South Devon and all are doing things slightly differently. But we have got reasonably good data from across our whole trust about a significantly sustained reduction in care home acute admissions. Obviously, that’s going to be multifactorial, but it’s nice to see the positive impact of EHCH work now that we’re a couple of years into it, not just on individual patients but our system as well.
Zoe It was great to have the DES because before we had so many different practices, managing different patients in different care homes.
The first thing we did was align everybody. That has made a huge difference. We’ve opened up communication between the 10 practices in our PCN’s 65 care homes.
Each practice is aligned to a clinical lead who is a district nurse. They can go in and see new patients and patients who have recently been discharged from hospital. They do a comprehensive geriatric assessment, if needed. They write a summary to the GP if there’s anything that needs actioning, but most things they can do such as making referrals to dietitians.
My next thing is to try to work with the clinical leads to improve training.
We’ve had a number of issues with death verification. In one case the patient was left for 14 hours. You don’t need to be a clinician to verify death, you just need adequate training and so I’ve been looking into that. Unfortunately, I’m getting a lot of backlash from the managers of care home saying that, if [a death] happens at nighttime, they would worry that their staff would not be competent to [verify] it. So we’re looking into that. We’re looking into getting ear syringing and dentists into the care homes as well.
Amit We’ve got three practices in Harpenden. Each practice has a named clinical lead GP for the care home. We currently cover three but we’ve got another two additional care homes being developed. We haven’t been told much about them so our clinical director (CD) is having discussions with the council saying, resources wise, how are we going to look after these additional two big care homes?
We have a regular multidisciplinary teams (MDT) meetings. We try something quarterly and invite all the care managers. We’ve got a team of pharmacists and physician associates that do the weekly contacts and GPs do the monthly reviews.
Sam We’ve got about six PCNs operating between central and west London. There are 14 older people homes and seven learning disability homes that are key drivers. In terms of the EHCH governance framework, we’ve split it so we’ve got the enhanced primary care support. This will look at everything about the weekly home rounds, [and] the MDTs, which are co-ordinated by the community matrons. Also, some of our key services such as hydration, nutrition and falls. We’ve also got palliative and end-of-life care, mental health and dementia care. That’s working in close collaboration with all the case-based partners in our area and to facilitate conversations between home managers and GPs. We have an open forum so we’re all in the same room together. Also we have digital [services] as well – that’s key for access to health and social care datasets.
Binodh We’ve got three big practices and around 30 care homes. This is a mixture of nursing homes, care homes and elderly mentally infirm (EMI). Unfortunately the learning disability homes are not included.
When Covid struck, we started by employing the care co-ordinators and then assigned 10 homes to each practice.
We have employed an advanced care practitioner as a paramedic practitioner, who is the main lead of the care home work. She’s supported by three care co-ordinators, and we work closely with the care home leads.
We are going to introduce a new system, Enact, a form to be filled in by the care home team to raise concerns. These forms are passed to the care co-ordinators. They don’t go to the GP practice any more. It’s like a triage. It asks have you done this? Have you done that? It makes [the care home team] think before they pick up the phone and ask for help for something simple. Once that [is up and running], we plan to have a meeting every morning at 8.30am, [when] the teams sit down and look at it all.
We’re working with a digital team, Plexus, which integrates primary care and health and social care records. We also did proxy prescribing requests – managers can request prescriptions. We’ve agreed that our PCN pharmacists will take an hour each every day [on presciptions for] the care home.
Dan Broadly, we’ve aligned the care homes – one care home to one GP surgery. We have a similar thing to Plexus but the care homes have access so they can request prescriptions directly from the surgery as if they were a patient.
That’s a practical thing we’ve done with our data sharing to enable the care holders to register as surrogates on behalf of their patients.
We’ve also got pharmacists aligned to the care homes. Their remit is to de-prescribe. It’s difficult because you’ve got to do so much Sherlock Holmes work. But while they’re doing the reviews, they’re doing that – their broad remit is [to stop] medication rather than start it. My hope is that I will be able to search the numbers of polypharmacy and that number will go down. It’s crude, but it’ll give us some impact numbers.
Victoria: You’ve mentioned training of care home staff. Do you see an increased confidence in care home staff to manage things before they pick up the phone to the GP?
Binodh Training does work. Just before the pandemic started, we gave training on chronic diseases and foot care. We helped staff to make sure that they get some observations first before they bring us in. They use a score to step up or step down. [They] don’t get in the routine of making calls. And we have fewer calls now.
We did a measurement to look at unnecessary admissions to hospitals last year. We looked at 15 care homes, five at each practice. At the beginning of the second quarter, we had about 15 unnecessary admissions. At the end of the second quarter, this number was down to one.
This is partly because of training and partly because our approach is practical. The main thing is the recommended summary plan for emergency care and treatment (Respect) form and how we interpret that – and it’s not easy. We can teach but [much comes down to] how we interpret it and how it’s put into place. It’s about things like [taking] fewer urine samples because there is proper hydration and hygiene maintenance and therefore we reduce the amount of unnecessary antibiotic prescribing.
From a training point of view, we’ve done a few sessions. One key thing was wound care management. We trained caregivers to offer the first basic wound care while residents wait for results for other things. Each home has a wound care box. That’s been well received. We just ran a programme on dementia and managing people with diabetes.
Zoe I’ve found over the last couple of years that I’ve worked with the same people and their confidence and clinical knowledge have increased so much.
I’m on call at the weekend for them as our locally commissioned service. The number of calls I receive now has reduced dramatically over the two years. Quite often [the caller] just wants to discuss their patient. It’s really positive and gives the staff more job satisfaction, which means there is less staff turnover.
Actually, I think a lot of senior carers would do more if they were allowed. That’s where the problem lies at the moment. I get told, we can’t do that; head office said no.
Katharine Yes, training is key. There’s formal trainings, [such as] verification of death training. There’s also the informal training that we are all doing and our care co-ordinators are doing week in week out. It’s relationship building, and narrowing the divide between health and social care.
Underpinning the success of training and advanced care planning is the relationship and the [knowledge] that your care co-ordinator is going to ring your home the next day, and you’re not going to have your ear chewed off by a grumpy GP [if you] escalate, [because you do it] appropriately and are able to evidence that.
Some of the challenge in the training is staff turnover in care homes. Maintaining any learning is challenging in this environment. But if you’ve got an established relationship, [the care home can] say, we’ve lost a member of the team that you trained to do insulin. Can I ask for this new member please?
It’s not by ticking boxes that we sustain the benefits we have achieved, it’s about doing the stuff that makes it work – that’s relationship building and training. And, without wanting to be too negative, the challenge is that neither of those is in the DES.
If I do this from a frailty GP perspective, the evidence-based intervention for our moderately severe patient group is comprehensive geriatric assessment. That’s loosely what the personalised care support plan is based on – you can only deliver comprehensive geriatric assessment with an MDT in primary care. If we didn’t have our additional roles reimbursement scheme (ARRS) team, our care co-ordinators, would we be able to deliver in an effective way? [Especially] when we’re acknowledging that a key part of that is knowing who to call with non medical problems that currently would go to medics who are totally the wrong people to sort this out. You need good care co-ordination. You need good social prescribers, understanding of the voluntary sector and understanding of your community teams.
Victoria: New arrangements can sometimes mean a difficult transition. How has that been for care homes and patients? Have you had any feedback on how this different way of co-ordinating care is working for them?
Amit Initially, it was a challenge because patients are used to being with the practice for years. So, building that trust is probably the difficult step initially and the main challenge. But from a care home perspective, it’s more efficient. I expect it to make things a lot easier.
I feel like it’s going well. We’ve had really good feedback from the care homes because they feel supported. Obviously these meetings are good in terms [of] discussing cases, if there are any difficult patients. We’re trying to incorporate training elements to cover anything that other care homes can benefit from.
Binodh When we assigned care homes to a practice, we did a lot of work to raise awareness among care home managers and residents. And their family members and our staff.
A positive thing from patients and relatives is knowing what’s happening. Continuity of care is important. I think that’s a key thing for everybody. And as long as there is clear instruction, they’re happy. We had really positive comments about the way things have been done in our areas. We have not had any negative comments at all. We are trying to develop a system where there is a lot of input from our team such as dietitians who visit care homes regularly. They train the caregivers about food, hydration and food care, and they also help with the chronic disease management.
Zoe The biggest challenge has been getting each individual practice to do the same thing. We’ve been meeting with the care co-ordinators for each practice and will set up the teams group to address that.
We had chat with 10 care managers way back at the beginning to ask what would be helpful for them as we didn’t want to do a tick-box exercise. So we tend to only discuss the very complex cases. We can be more focused on the complex patients and we have the integrated care manager who can co-ordinate and invite different members depending on the case that’s being discussed.
Most of them said that with the new working – the way every care home has a dedicated phone number, email and so on – means that things are dealt with very quickly. It’s usually within a week, especially with the ward round.
Dan We have an associated care co-ordinator. Our care co-ordinator picks up the non clinical stuff – [for instance] if the care homes have got a problem with dressings. That’s been really good because it’s helped the homes in a very practical way.
Victoria: How do you see the EHCH evolving this year and beyond?
Dan I don’t think this sort of thing can proceed without PCNs because you need an MDT to manage it. I deeply disagree with the BMA’s point that PCNs have failed thus far.
We’ve now got a GP with a specialist interest in frailty. They do the care homes proactively and reactively, and it’s a definite skill set. They know the patients, they know the risks to take and they can push the boundaries based on previous conversations. I deeply believe in frailty as a service. Ultimately, I think it’s a underserved part of our population for a whole variety of reasons.
Katharine If you look at the trajectory for our ageing population size, our frailty trajectories and also our geriatrician numbers, we’re going to have an escalating number of severely frail people living in our communities with nobody to look after them. I realise it’s a Marmite [concept] because some people hate it but GPs are expert at holding risk in the community for our frail patients. We can share expertise and knowledge with our wider MDTs to support that. It would be bonkers to leave this – we’ve got to think of how much progress has been made in that space over the last couple of years. [Yet] if no funding is attached, look at how stretched our workforce is and what other things are going to be put out for us to do. How are we going to [run this service]? I don’t have an answer for that.
Sam We have used this as a starting point. There are local needs that can be looked at as well. The EHCH framework does provide focus and we’re all signed up for it. The other two main work streams are workforce and personalisation.
At this point we’re trying to standardise the London personalised care plan so it’s standard across both boroughs, making sure the social ambitions of the resident are captured.
For workforce, we’ve got a pilot running from Imperial College [University of London]. We have a doctor who was undertaking a baseline activity on the early signs of deterioration and understanding where homes are, how they access services, how vital signs [are] taken. The plan would be to offer specialised training to those homes, to ensure the workforce is trained.
Binodh There are loads of streams of work happening across the system. They have to be streamlined into this, rather than [being] isolated pieces of work. This bit of work that we’ve done can help to bring care back into the centre to where the person is. It has evolved from there. That’s what we’re doing at the moment and I say this has to carry on. We need this support. We need to have these people in place to carry on this good work.
Zoe Ideally, the next step would be opening up communication between primary and secondary care, the ambulance service, out-of-hours and hospices. That’s one of the biggest barriers in trying to manage patients and make significant change. Everyone has their own contracts and their own funding.
Amit Do we want to keep this service running? Yes, absolutely. And the demand will only go up. Where do I see it going?
I feel we need more resources to help us. We’re trying to get an elder care consultant attached to us, but I think there is a contract issue. How are they employed in primary care? So it hasn’t happened yet but we’re trying to work out how to do it.
We’re trying to get specialists to help us – to do a mini ward round to support GPs and the PCN staff, the physician associates and the pharmacists. It would be more efficient and give more confidence to the care team.
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