The St Triduana’s Medical Practice in Edinburgh where I am a GP partner looks after three large care homes that together have over 200 residents.
When a local enhanced service (LES) for care homes started in Scotland we wanted to find a way to create meaningful, detailed and specific anticipatory care plans in an efficient way.
Our feeling was that many anticipatory care plans were worded quite generally and used phrases such as 'try to manage [the patient] in the care home if possible'.
We felt this did not give sufficiently clear guidance to care home staff as to how best to manage acute deterioration in a resident's health.
As a consequence, there were emergency and out-of-hours admissions in situations where the patient could have been cared for without hospitalisation.
A vague anticipatory care plan may also not fully convey the wishes of residents of care homes who want to opt for more interventionist treatment.
However, we were faced with the prospect of conducting more than 200 face-to-face interviews with care home residents or their relatives to create the robust anticipatory care plans we were looking for.
Doing this would take up an estimated 100 hours of doctor time – a daunting prospect. I therefore designed a questionnaire to be given to care home residents. There was nothing in the literature that I could find that we could borrow, so we came up with our own questions.
This asked questions about what treatment the patient would want if they suffered a stroke and could not communicate, a serious infection or became unable to eat or drink.
|Questions for care home residents|
Before their anticipatory care plan is draw up, residents are asked the same two questions about their care preferences in the event of:
Q1 Would you want to be admitted to hospital for invasive treatment such as drips, antibiotic treatment into a vein and feeding via PEG tube (feeding tube into stomach)?
Q2 Would you want to be kept comfortable inyour current environment with every effort made to relieve any distress that you are experiencing?
Care plan discussion
For those residents who lacked capacity a similar questionnaire was given to relatives with the additional option to call the resident’s next of kin prior to admission to hospital. The resident's questionnaire is then used to form the basis of a discussion on their anticipatory care plan.
Next of kin are invited to discuss their responses with us before the anticipatory care plan is drawn up.
We have found that using these forms has allowed us to generate anticipatory care plans with very clear instructions to care home staff as to how to manage acute serious illnesses in a way that is closely linked to the wishes of the patient.
This has been done with the minimum of doctor time, although sometimes it takes a little time to get the questionnaires back or to go over them with the mentally competent residents.
From questions to plans
The questionnaires are given out when new residents arrive. We believe our anticipatory care plans have certainly enabled care home residents who become seriously ill to be treated in line with their wishes.
Once we have the responses it is relatively straightforward to generate a care plan.
Our care plans focus very heavily on the key question of how to manage a sudden deterioration in a resident’s condition. They specify under what circumstances calling 999 would and would not be appropriate in as detailed manner as possible.
What they do not do is repeat lots of information that is available in the care home’s records about next of kin and the like.
The background medical information is pulled in automatically from our clinical system.
I am the lead partner for our care residents work, supported by one or two of the associate doctors and occasionally another partner will do a session.
Our phlebotomist visits regularly and our practice nurses occasionally to do chronic disease reviews.
Impact of the plans
Unfortunately the impact of the plans on reducing hospital admissions is hard to gauge as we do not have accurate data for the period before their introduction to compare with the current admission rate.
There are some residents that are keen for active intervention in the event of serious illness and it can be very helpful to have that documented in advance to guide us and unscheduled care doctors.
Occasionally we find relatives are reluctant to deal with the issues involved or find the questionnaire too impersonal. We always offer to meet and discuss the questions in it, but some still do not like it.
There are others who are delighted that we take such a proactive approach.
Sometimes it takes a little longer than is ideal to generate the anticipatory care plans, but it is far better to have a plan that is likely to guide patient care than have to one in place quickly when a patient becomes ill.
St Triduana’s Medical Practice, north east Edinburgh
GPs: Five partners, three associates (salaried GPs) plus ST1s, ST3s and FY2s.
List: 9,500 patients with significantly higher than average elderly including over 200 care home residents; socially mixed with pockets of significant deprivation. The practice always accept patients in care homes for whom St Triduana’s the lead practice locally.
LES for care homes:
- Dr Mackay is a GP at St Triduana’s Medical Practice in Edinburgh