An unsustainable way of working

The practice looks after a care home with 80 beds.  Residents range from a variety of age groups from young through to the elderly, and residents with complex care needs. The practice team mapped out the process it was following for managing the care home to identify where issues existed.

• Duplicate requests were coming into the practice from various sources e.g. care home staff, pharmacy, family members. Some requests could be duplicated as much as three times, creating wasted effort as a number of staff could unknowingly be working on the same query e.g. a GP and pharmacist separately trying to resolve the same medication query.
• Miscommunication was leading to complaints e.g. family members chasing a query that had already been dealt with by the practice but the family not been made aware.
• A weekly ward round that should have taken 3 hours was taking approximately 8 hours. This was due to the GP having to see most residents whose queries had built up during the week and spend time adding patient information onto EMIS. As a result one whole day of GP time was being taken out of the practice every week.
• The process seemed to be reactive in the main, creating high volumes of queries. Two members of staff could easily spend their day dealing with only care home queries; admin who picked up the initial requests and a pharmacist (as most queries were medication related).

The pressure on staff was high, causing emotional distress. There were also concerns the process gave scope for errors, particularly around medication. Having a better understanding of where the issues were, the practice was able to prioritise where it needed to focus its efforts on making changes.

Working more collaboratively

The current process demonstrated that the care home and local pharmacy had become heavily dependent on the practice as its ‘go to’ place for queries, some of which they could resolve themselves. The practice addressed this by developing a more collaborative approach to working with both.

• Working with the care home manager, the practice was able to set up a proxy laptop with password, email and EMIS access for the home.  This allows care home staff to add patient data to the system, reducing the admin burden on the practice.

• A form was set up on EMIS which care home staff must complete now to submit a query. It requires the resident’s history in relation to the issue and where possible, clinical information that was not previously provided but would help the practice resolve the query quicker e.g. patient sugar levels.
• Any medication queries that can be dealt by the local pharmacy e.g. change in the dose/new medication review or missing items on monthly medications, are directed to the clinical pharmacists who directly liaise with the dispensing pharmacy. This has hugely reduced the volume of queries coming into the practice.
• With support from the practice’s clinical pharmacists and care home nurses, the practice has given the pharmacist from the local pharmacy access to directly request the monthly medications, leading to more streamlined processes and reductions in errors.

Delivering a more proactive service

A healthcare assistant (HCA) is now the first point of contact for the care home. Every morning they call the care home manager and also speak to a member of staff on each of the three floors, to check the health of residents and any concerns. The calls initially took one hour every day but over time as the process became embedded and smoother now only take 20 minutes.

A more proactive service has strengthened the practices working relationship with the care home and reduced duplicate queries.

Virtual and face to face ward rounds

The weekly face to face ward round has now been replaced by one virtual ward round a week and one face to face ward round a month in the care home, the latter with PPE and following the appropriate national guidance. Should any urgent queries arise in between the rounds and the resident need a face to face visit, the practice will arrange this.

Depending on resident needs, the practice will call upon members of the multi-disciplinary team, community drop in and geriatrician for support, which is working well for both the residents and care home staff.

Impact

During the three months of support the practice received it achieved the following.

• Released 5 hours of GP time per week that were previously spent on face to face ward rounds. The released time is helping GPs to look at ways to deliver more proactive and palliative care for the home.
• Duplications have reduced which helped to collectively release 12 hours a week of admin and a clinical pharmacist team member’s time. The time released is allowing the practice to improve access for patients, by offering more patient facing appointments and conducting long term condition reviews to improve quality of proactive care.
• The practice has shared the work it has done with other practices in the borough as good and useful practice.
• Team working and staff morale has increased in the practice. Having the skills and knowledge of quality improvement tools and approaches has empowered staff to continue making improvements to the way they work.
• Working relationships with the local pharmacy and care home have improved. The work has helped nurses develop their skills, reducing the dependency on the practice.
• The care home residents are receiving a more efficient and safer service. Residents do not feel they have been forgotten or abandoned, in turn care home staff do not feel like they have been left alone with no support.