Case study summary
Barrow and Millom Primary Care Network (PCN) is made up of ten practices in Morecambe Bay, serving a patient population of approximately 68,000. The practices had started a collaborative project two years ago to work more proactively with care homes but had come to a standstill. The PCN participated in the Productive General Practice (PGP) Quick Start programme to kick-start the work and progress to implementing weekly care rounds. PGP Quick Start is delivered by NHS England and NHS Improvement and is part of the support available through Time for Care.
Design and pilot a standard weekly care round approach and process to be rolled out across the PCN.
Kick-starting the project
For two years practices in the PCN had worked collaboratively to try and deliver a more proactive service to care homes. Whilst there was a great deal of goodwill between the practices progress was slow and lacked proper direction.
There are 14 care home units in the area and ten GP practices. Each practice used its own processes which caused difficulties for the care homes who had to accommodate ten different ways of working. One of the significant issues for both sides was managing patient visits, which was time consuming and inefficient.
Following discussions with the care homes, which helped get their buy-in, the PCN prioritised piloting a standard approach and process for conducting weekly care rounds. If successful, the process would be rolled out across the PCN.
Understanding where there are inefficiencies
Two practices in the PCN took part initially in the pilot. They began by discussing with the associated care homes what typical issues the practices and care homes were experiencing with the current process of managing patient visits.
- Getting through to practice phone lines to arrange a visit was hugely time consuming. One care home was having to allocate a member of staff every morning to the task, which could take up to three hours.
- GPs did not feel that all of the visits flagged as ‘urgent’ by the care homes were ‘urgent’.
- 22% of appointments did not need to be handled by a GP and could have been dealt with by another healthcare professional.
- Information exchanged between care home staff and practice reception staff was not always accurate. Sometimes GPs would see residents with different presenting issues to those they had been called out for.
- GPs could be spending up to three hours each week travelling to care homes to conduct individual visits.
The findings were shared and discussed with other practices in the PCN, who overwhelmingly found they were experiencing similar problems.
Piloting weekly ‘care’ home rounds
The PCN and care homes worked collaboratively on a new approach.
Prior to the visits starting the GP and care home manger agreed a consistent day of the week and time for a care round to be held, along with a follow up telephone call to take place three/four days later. The GP will be at the home for two to three hours to see all the residents who require a visit, allowing for enough time to enter patient notes on the system and complete actions. An assigned senior nurse is put on the rota to meet and support the visit (where possible the same individual will support each week), helping develop the skills of care home staff with the GP providing coaching.
- The care home collates any non-urgent concerns during the days prior to the visit. They provide a list to the practice of residents who need to be seen and why, and those where only a discussion about care is required. The list is emailed securely to the practice an hour before the visit start time, reducing the need to go back and forth with queries prior to the visit.
- If no resident requires a visit the practice is notified in advance and will arrange to discuss any concerns by phone if necessary.
- On arrival the GP and care staff will discuss the list and agree action, including any changes in residents that need to be seen. Staff members who know the resident well and are aware of the issues raised will be present.
- Once the visit is complete the clinician will update the patient record and complete any actions (for example, booking of tests, prescribing medication) on EMIS via their secured laptop. Actions are shared with the team members involved.
The following processes are in place for after the care round.
- The care home can contact the GP straight away for any concerns arising after the visit that require urgent attention.
- The GP makes a weekly follow-up call to the care home senior team member three/four days later to discuss any concerns.
The pilot was tested over three months and received positive feedback from the care homes and practices. Some changes were identified, particularly around the need for correct IT to be in place for example, access to a practice laptop and a dongle that would provide a secure internet connection to access EMIS.
Better exchange of information
One of the issues tackled during the pilot was inappropriate visits. Exploring the reasons behind why these were occurring, the PCN found it was due to lack of accurate information shared between the care homes and practice reception staff.
Both staff groups were trained to use the SBAR tool (situation, background, assessment, recommendation), which provides a more structured way to communicate information that requires a response from the receiver.
- Care home staff now complete a standard SBAR form where they provide specific information and detail about the resident and relating problem.
- The form is securely emailed to the practice, avoiding the need to phone. On receipt of the form reception staff will review the information and forward on to the appropriate clinician for action.
- If referred to a GP, the GP will determine whether it needs a call or visit. If urgent a visit is arranged, if not it will be added to the next care home round.
The use of SBAR has significantly strengthened the care and reduced the amount of communication coming into the practices from care homes.
When the COVID-19 outbreak first hit, the PCN was able to quickly isolate care homes and each practice able to address the problems the pandemic created.
As an area it was able to satisfy most of the requirements in the ‘primary care response to care homes during COVID-19’, through the work it had done on the programme. The PCN also feels well prepared to deliver the requirements of the ‘Enhanced Health in Care Homes’ DES from October 2020.
- The proactive care delivered to care homes has increased the number of residents the GPs see by 36% per month. Whilst this is an increase the GPs are spending 30% less time traveling and on admin, as the visits are pre-planned and appropriate.
- There has been a 57% reduction in inappropriate contact from care homes to the practice. This has helped free up the phone lines for other patients and given care home staff time back to deliver more care for their residents.
- Working relations have developed hugely between the practices and care homes. Care home staff now feel more confident about decision-making and better understand when a visit is required or can wait until the next weekly care round. Practice reception staff are also more confident about what needs to be referred to a GP or other clinician.
- Residents in care homes are receiving a better, more consistent and proactive service.
- The success of the pilot has encouraged other practices across the PCN to look at implementing it across their patch.
“Thanks to Productive General Practice Quick Start we’ve been able to kick-start our care homes project. We’ve achieved more in the last three months than we did over 18 months!”
Sarah Arun, Clinical Director, Barrow and Millom Primary Care Network
“The relationships between GP’s Practice and Medicines Managers and care home staff has improved so much, the beneficiaries are the residents who now receive timely, professional and proactive care. It takes commitment on both sides but the results are impressive for all involved.”
Barbara Johnson, Director of Nursing, Risedale Care Homes
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