The Housebound Service
Claire Kaye, GP, Schopwick surgery
Our surgery, Schopwick, is set in a beautiful part of leafy Hertfordshire on the borders of North London. We have a large elderly population and despite the fact that our clinical team were trying to provide the very best care to all patients, we felt that our housebound population was not receiving as much time and attention as we would like. I am a salaried GP at the practice and the partners asked me to devise a mechanism for providing better care to this vulnerable population.
In January 2015 I set up the ‘Housebound service’ in close consultation with the rest of the surgery and community team and I am pleased to report it has been a great success.
In general, housebound patients find it difficult to access medical and social support. As GP’s we are often limited for time on home visits. As a result we commonly manage the immediate acute problems when we visit a patient at home but we find it difficult to sort out wider issues. This, in my opinion, contributes to patients going in to crisis at some point. For example, a patient who has had a fall may not just need their lacerations and head injury assessing. The cause of the fall is vital. They may have fallen because they have undiagnosed memory issues or underlying pathology such as polymyalgia rheumatica or arthritis. They may be struggling to look after themselves and need more social support. If we can make small changes early then in theory patients should have better outcomes. This was a hypothesis which I hoped to prove. Patients had also reported to us that they often didn’t know how to or who to seek help from if they had a more of a chronic issue, such as becoming frailer, and they often didn’t want to ‘bother the GP’ if there was no specific acute issue.
The aim of the service is to provide holistic care of the housebound population. It focuses on continuity of care so that patients know who and how to get help, with more chronic issues, when needed. The service is ‘in-house’ and so patients have said they feel reassured that their GP practice is their point of contact.
Each housebound patient has a one hour holistic consultation with the lead GP at home at least annually. Patients also receive at least one follow up telephone consultation approximately one month later with the lead GP. If necessary they have more face to face or telephone consultations throughout the year. A template was created based on the Comprehensive Geriatric Assessment which is used during the face to face consultation and a user friendly computer version of this template was also produced to enable all the information to be entered correctly on our IT system. The template covers all medical issues, medication review, falls risk assessment, mobility, nutrition, memory and mood assessment , resus status and social issues.
Continuity is vital to the success of the service and so the lead GP can be contacted, at the GP surgery, by the patient when needed, however the patient still continues to see their usual GP for acute issues.
We also wanted to ensure that we work closely with the multi-disciplinary team, including the practice ‘carers champion’, CCG navigator and local allied health professionals including OT, physio, social services and memory clinic to provide joined up care.
The other important part of the service is that any clinical or non clinical member of the surgery team can refer a patient to the Housebound Service. There is no paper work involved and no criteria except that the patient must be housebound.
The impact of the service
Anecdotally the patients and relatives seemed to really value the service. Comments included things such as ‘ this service is heaven sent’, ‘we have been desperate and didn’t know where to turn’ and ‘at last I know that someone cares’. A Survey Monkey was conducted retrospectively interviewing 69 patients about their experience of the housebound service. The outcome were very successful. Patients and relatives felt that the service was useful and accessible. Patients said that they valued time and continuity with their GP. They felt reassured and that the surgery cared about their overall wellbeing.
Also multiple new diagnosis have been picked up including breast cancer, PMR, OA, depression, dementia and severe AS. A lot of this patient group either didn’t realise anything was medically wrong or they didn’t want to ‘bother the doctor’.
An audit was also carried out looking at a time period before and after the Housebound Service was started. It showed that this project has contributed to reducing home visits by 29 visits in a one month period when looking at 2 comparable points in 2 consecutive years.
Interestingly, staff have also reported that they have found the service helpful. Practice staff, (including non-clinicians) who have concerns about a patient have direct access to a more in depth consultation from the lead GP and patients can be discussed easily, when required, in practice meetings. It also helps to give clinicians an idea of a patient’s baseline which is useful when assessing an acutely unwell housebound patient.
One of the joys of this service is that there is virtually no red tape. There is no referral paperwork to fill in and no discharge system. It is simply an extension of the usual service provided by the patient’s GP. The project has improved housebound patient diagnosis, follow up and overall care to a vulnerable population group. It also allows for careful care planning aiming to reduce falls and provide better patient care.
We have now extended the model to involve our community matron which includes a weekly ‘ward round’ type discussion of current patients. The lead GP sees patients on alternate weeks but is available for messages on a weekly basis. Our community matron also sees patients on an alternate week basis. This development is providing even closer links with the community team which is in turn benefiting our patients.
If you would like more information on implementing this Bright Idea in your practice, please email firstname.lastname@example.org