Training the future doctors in Hospital at Home: the Integrated Care Fellows Training Programme

Rebekah Schiff has been a consultant geriatrician and general physician at Guy’s and St Thomas’ NHS Foundation Trust since 2004. She has extensive experience in inpatient care of older adults both in hospital, intermediate care and community settings. She tweets @rebekah_schiff

With the national agenda to create virtual wards has come an increasing demand to develop Hospital at Home (H@H) services. Guys and St Thomas’ H@H, operational since 2014, “takes the ward to the patient’s home”. A multi-disciplinary team visits each patient daily, providing level 1 ward interventions and care, supervised by Consultants in Geriatrics and General Medicine. The team have excellent links to local hospitals, community services and London Ambulance Service with pathways of care across the integrated systems.

A few years ago we realised we had two issues. There were skills gaps in our team with insufficient capacity for day to day medical decisions such as planning and interpreting investigations, prescribing, home visits, advance care planning and medical discharge decisions. We only had senior doctors; GPs, who saw complex new referrals, and consultants, who advised on medical management of the whole ward twice weekly and visited selected complex patients. At the same time, we recognised that doctors required training in community medicine. We needed to develop doctors who understood how H@H fits into pathways of care to enable them to utilise these services for their future patients and we needed to train the future GPs and consultants to work within the service.

Out of this need we developed our Integrated Care Fellow (ICF) training programme. Now in its fifth year, this programme for doctors in their 3^rd year post qualification (FY3) is designed for those considering future careers in General Practice, General Medicine or Geriatrics. The programme lasts one year with every ICF spending four months in each of H@H, acute front door frailty service and an older persons’ ward to experience care of older adults living with frailty across an integrated care pathway.

The H@H roles have bespoke learning objectives:

• Understanding the challenges and advantages of medical practice in people’s own homes
• Developing skills in community home visits including
  
  • assessment and management without easy access to radiology
  • risk assessment of home vs hospital,
  • consent and application of the Mental Capacity Act in the community
• Community MDT working
  
  • Remote clinical advice provision
  • Community prescribing

For those of us organising the posts, there has been and continues to be a lot of learning. Working in the community at this early stage of a doctor’s career creates new stresses. Compared with hospital working, the team is smaller and geographically dispersed such that doctors can feel relatively isolated from their peers and the usual peer support. Making medical decisions for patients you have not met can be disconcerting. Furthermore being organised is essential: forgetting an item required during a home visit is not quick to fix. A thorough induction and easy access to consultants is key to help resolve some of this.

We have developed a three-pronged induction approach: a)information provision on key topics such as safety equipment bags, community prescribing and computer systems; b) shadowing both doctors and nurses on visits;  and c)running a practical skills SIM course. The latter was designed by the ICFs who wanted practice with mixing IV medications, setting up IV fluids, catheterisation, blood glucose testing and point of care blood testing. These are procedures that nowadays nurses tend to do in hospital wards but H@H doctors need to be able to do on home visits.

So how did it feel as an FY3 doing this role? Here is Dr Megan Collins’s experience:

I was initially apprehensive on beginning my rotation with the Hospital@home team, having really only had medical experience in a hospital setting, where there was always another doctor close by with whom I could check my decisions or ask to ‘eyeball’ the patient if I had any doubts. Seeing patients in their own home, frequently by myself, seemed like an alien concept and very much outside my comfort zone. However, after my induction period, shadowing, and seeing my first few patients independently, it quickly became an exciting and rewarding learning opportunity and job.

One of the biggest challenges I found in the role was having to become a more independent clinician at such an early stage in my career, although I soon learnt that the consultants and GPs were happy to be contacted to discuss cases and support as much as needed. Initially I found prescribing for patients I had not met face-to-face nerve-wracking. I also found it frustrating on less patient-facing days as there was often a list of administrative tasks that needed to be done by a doctor, such as ordering scans and checking blood results.

However, these challenges were very much offset by the valuable insights and experience I gained, which I have taken forward into subsequent roles back in the hospital. My clinical judgement and understanding improved exponentially by assessing patients and developing management plans without having investigation results at my fingertips. I also developed vital skills in being able to safely give clinical advice remotely. I gained an awareness of some of the impractical things we initiate in hospital for patients, which they are then not able to continue in their own homes. Overall it has given me the necessary awareness so that I am now better able to sensibly and safely plan patients’ discharge home from the wards. For me, being able to treat patients in their own environments and respect their preferred places of care, and sometimes death, was extremely rewarding. It is a role that I am certainly now considering incorporating into my future career.