Assistant Practice Manager Joanne Drewery describes the support Clee Medical Centre give to care home residents registered at the North Lincolnshire practice, which has led to improvements in communications and the ordering of medicines.

Supporting an ageing population in Cleethorpes

We’re aware we have an ageing population in Cleethorpes. In October last year the GPs at our practice wanted to ensure patients were seen regularly especially as many patients moving into care homes could no longer be brought into the practice. We had discussions on how we could help them receive the regular attention required. This included routine reviews for long term conditions, medication reviews, health checks and forward planning so that when a patient reached the end-of-life stage their wishes were at the forefront of their care.

From this we realised we had to find the best way to help improve relationships and communications with the care homes, our patients residing in them, and the families that needed keeping in the loop regarding their loved one’s care.

Doing the detective work

Initially we set to work finding out who our patients were and where they were residing. For example, checking we had the next of kin details, those of the manager of the home, arranging points of contact.

We then reviewed the contact methods available to the care homes to attempt to find a quick and simple way for them to contact us, both in an emergency or for routine prescription ordering / enquiries.

We then asked if we could visit the care home on a regular basis to see our patients. The care homes loved this idea and quickly accepted the offer. We used their own pre-organised events, such as coffee mornings to capture all the residents and staff, introduce ourselves and explain they would be seeing us regularly in the building. This unexpectedly resulted in transfers to our practice as other residents wanted to benefit from our visits and this offer of continuity of care.

Joining the dots to create a model for care home relations

We now have several care homes where over 95% of residents are registered to Clee Medical Centre.

The care homes have encouraged this with families and residents to help make things easier for their staff too, by reducing the number of separate surgeries they needed to contact in any one day.

As our approach proved popular, we decided to have a dedicated afternoon where one of the GP partners would attend care homes on a rotational basis. Moving forward we intend to include nursing staff in these visits and continue to liaise closely with our Primary Care Network (PCN) frailty nurse and local Macmillan services.

 Improving communications

We communicate with the care homes weekly by either email or telephone, and they are pre-contacted to ensure they are aware of the visit date which encourages them to name any specific patients they feel need to be seen by the doctor, as well as new residents who we have not previously met.

Going back to the initial thoughts on how we would like to improve communication with care homes, the practice decided it would be good to set up a system to contact the managers of the care homes regularly and build a rapport, working together to find  mutually beneficial ways to assist the wellbeing of the resident/patient, and ironing out any difficulties care homes previously found when contacting the practice.

As all the care homes have NHS email facilities, we chose this route to aid contact for times when urgent/time-sensitive communication was required (e.g. to exchange details when pre-10.30am visits were requested). Prescriptions requests have been given their own dedicated email inbox, and we are trying to obtain proxy ordering for our care homes where possible to make it more streamlined for all parties.

All care homes can still use the main phoneline at any time they chose, and the managers always have a direct dial number that is not the main line for any urgent issues, should anything unexpected occur.

From initial conversations, we realised one of the frustrations from both sides was around referrals requests. To meet this challenge, we built specific templates with the suggestion that these could be stored electronically at the care home and completed by staff who know the patient well, then emailed to the practice with the information. From there, the clinician could complete the remainder of required forms and refer as appropriate.

This saved time on both sides and the quality of the information on the referral was greatly improved. Additionally, the care home had an electronic copy for their records and could refer to it if any further changes were noted in the future.

Through two-way communication and listening to the feedback we actively seek from our care homes, we can boost awareness of national and regional initiatives in the care home. For example, vaccination campaigns and awareness of relevant support weeks or support in general for wellbeing activities locally, which a lot of the care homes would not ordinarily receive notification of via the ICB or external sources.

Our team is led by our Assistant Manager who makes the initial contacts and arranges visits / calls to explain what we can offer and how it can benefit both parties.

The internal prescription team pick up from the prescription emails. Our practice email administrators, collect any other emails from care homes, and action as needed.

Successfully overcoming bumps in the road

The biggest bump in the road to overcome, has been getting the message disseminated to the staff within the homes as many work on a part-time basis, but with time and patience this has been addressed and seems to be running smoothly.

The only other small hurdle came when a care home requested that we take over the whole of their residents’ care and it was a home that fell under a different PCN.  As geographically it made sense, ICB colleagues transferred the home to us and our PCN without any request from ourselves.

Where we only have one patient / resident the preference from these managers has been for telephone contacts on a less frequent basis, which we have been able to meet, but to ensure ongoing quality of care we intend to keep all options open to the home.

The personal impact of making a change

As a result of our work in this area, communication is clear and quick – medication reordering is more streamlined, and medication changes are completed in writing via email.

Our care homes have reported in a recent survey that in general they feel they are supported and have less concerns about getting their residents the attention they need, at the time at which it is needed.

Most important of all, care home residents and their families know they are getting the care they need from us and are really appreciative of the improvements we have made on their behalf. When you work for the NHS it is all about the patients, and when you make changes to improve processes that makes things better for them – it is worthwhile on so many levels.

Joanne Drewery, Assistant Practice Manager at Clee Medical Centre