Enhanced Health in Care Homes: How is it for you?

Dr Maggie Keeble is Co-Chair of the GeriGPs Committee, and for twenty years worked as a full time GP in Worcester. She stepped down from partnership in 2014 and now has two jobs. As a Care Home GP she provides general medical services for a local practice to five care homes with a total population of over 160. She also has a leadership role with the Integrated Care for Older People (ICOPE) programme in Worcestershire bringing local health, social care and public health organisations, the voluntary sector and older people together to work collaboratively to make Worcestershire a great place to live in later life.

Those of us working a lot with care homes have been involved in implementing the Enhanced Health in Care Homes Directed Enhanced Service (EHCH DES) that came into effect last year. Whilst the specification is clear, I suspect there is considerable variation in how this is being implemented in different areas. I thought it might be helpful for others to hear how it’s going in my patch: what is going well as well as what could be going better. Feedback from others would be useful to get a sense of variation across the country and how we can best share the learning and the ‘quick wins’.

I work for Worcester City Care Home Team supporting eight care homes. I work for the team two days a week and have the support of three Advanced Clinical Practitioners and three Care Coordinators. The team will expand over time to cover more of the homes in the area but as the staff are all new in role, the plan is to bring other homes into the remit of the team as they become more experienced. In the meantime these additional homes are supported by their individual practices, who have developed a relationship with their homes over time and who were keen to maintain their involvement.

What is working well:

1. Individual Care Home MDTMs – we hold a weekly meeting with each home. This is done via Microsoft Teams which has been an incredibly positive development with great engagement. The team comprises myself, representatives from the care homes including a nurse (if it is a nursing home), as well as the manager or deputy manager, a district nurse for residential homes, our care home pharmacist, the administrator for the Care Home Team and one of the care coordinators. Each MDTM has a structured format – we discuss new residents, any ambulance call outs/hospital discharges, one or two ‘birth month’ reviews and then any unstable residents – eg acute delirium, increased falls, approaching the end of life, behavioural issues, swallowing issues etc. Each meeting is minuted and the minutes are sent to all participants including the planned birth month reviews for the following week to allow people to prepare.
    
2. Care Coordinators - the care coordinators have been appointed through the ARRS (Additional Roles Reimbursement Scheme) monies and are employed by a charity in Worcester. They have a range of backgrounds and skills but are not healthcare professionals. Their role is to liaise with residents, families, care homes and social workers where relevant, to gather information about residents’ social circumstances and background. They enquire about existing health attorney status and track down the documentation if it exists. As they grow in experience and confidence, they are beginning to enquire about wishes and preferences in relation to future care plans and will touch on RESPECT plans and DNACPR status if they consider it appropriate to do so after initial enquiries. It has been a joy working with them and is it exciting to see this new role develop.
    
3. New Residents – each new resident has a Comprehensive Geriatric Assessment to enable the creation of a personalised Care and Support plan. With other GP colleagues in the county we have developed a Worcestershire-wide Frailty CGA clinical template on EMIS which enables us to easily code all relevant information. The template cannot be closed without adding a Rockwood Clinical Frailty Scale score. We have also developed a very simple Care and Support Plan document template, the majority of which needs to be completed using free text information but once completed can be quickly updated as the individual’s situation changes.
    
4. Birth Month Reviews – every resident has a full CGA review in their birth month. This enables their Care and Support plan to be written/updated and is an ideal opportunity for a structured medication review. The Care Coordinators take the opportunity to talk with the residents when they are able to do so – they are still very restricted in their ability to visit during the pandemic – and will also speak to the relatives when appropriate and the care home staff to update functional ability status. The care home provides us with an up-to-date set of observations including the weight, and advance care plans are reviewed and updated as appropriate also.
    
5. Daily Team Catch Ups – the team on duty for the care homes meets via Teams every day at 8.30 and again at 13.45. We review the ‘hot list’ ie virtual ward list of unstable residents and review any visit requests that are emailed in from the homes the night before. Everyone in the team is updated and visits allocated for the day. This process is repeated at the lunchtime session with an opportunity to hear about visits earlier in the day, to agree further interventions or to arrange a GP face to face visit if necessary. This has become a very useful opportunity to educate on a daily basis as the ACPs come across clinical situations with which they may not be familiar.

This may all seem very time consuming and complex but I should reassure you that the MDMTs are not taking that long to do – half an hour for smaller homes, usually under an hour for the bigger ones. In addition, this process significantly speeds up the ability to assess residents holistically in an acute situation and shares the burden of information collation across multiple individuals. The standardisation of processes enables wider teams to have a consistent approach across the care homes and amongst different GPs.

What could be going better:

1. Social Care - we still struggle to have useful engagement with social workers. The structure of social work in the county means that multiple social workers are involved with residents in any one home and attendance at every care home MDMT in the county once a week (179 homes) is impossible to facilitate. We are having constructive conversations with our County Council colleagues to consider a way forward.
    
2. Engagement with Geriatricians and Older Adult Mental Health services remains limited. We have some excellent and very committed Geriatricians in the county but they remain under-represented in the local Acute Trust and have very limited ability to outreach and engage in the community. A PCN-wide MDTM for complex cases has been considered but more work needs to be done to bring this to fruition.
    
3. Integrated Care and Wellbeing Record – at present there are 9 clinical record systems in the county, making it impossible to date to have a single version of the truth. Exciting plans are in place to bring all this information into one combined record viewer in the foreseeable future. A dream of mine for many years, if this comes off it will revolutionise our ability to provide joined-up care across the system.

Despite the restrictions of the pandemic and the devastating effects of coronavirus on some of our care home residents and colleagues, I have seen really positive change over recent months in how we support care homes, much of which has been enabled by the EHCH DES. As we gain experience and develop the service, I'm more optimistic than ever about improvements in the quality of care provided to care home residents across the country.