Home visits can be a daunting prospect for a locum team member. Providing them with a few extra little details about the patient they are visiting, can go a long way to helping the locum get the most out of their time, writes Dr Richard Fieldhouse.
Home visits can be particularly challenging for GP locums, often involving knowledge of the local area and ‘soft’ information about patients that a newcomer to the practice may not know. But given some useful information on what they may expect on a visit, locums are better prepared to take on this often time-consuming role.
This case illustrates the benefits of spending just a few minutes providing some easily-accessible extra information for the locum.
Case study: Mr Dinwoody
Your regular GPs may hear the phrase ‘Mr Dinwoody has had a fall’ and see, in their mind’s eye, an instant image of the journey to his address in a new-build retirement flat just out of town.
They may know the keycode to his doorsafe by heart and know instantly that he lives alone, apart from a very annoying dog who has to be locked in the kitchen so the patient can be heard in peace.
They may also recall that his wife died three years ago and he misses her bitterly and tends to cry when he talks about her, but has a son nearby who visits him most days; that he has had right-sided weakness and very limited mobility since his stroke eight years ago (the stroke was recorded in his notes, but not the residual disability); that he has been unsteady on his feet but has had the full involvement of the community care services, with home carers visiting twice daily alongside his family visits.
But how does a locum GP approach this scenario? Clutching my paper printout visit summary, and even having checked his computer notes before I left the practice, I knew none of this. His address does not appear on Google Maps, causing extra travel time. I didn’t even know I’d need a keycode until I’d been standing on the doorstep waiting for a reply for five minutes. Eventually, and by now rather stressed, I see an elderly man with right-sided weakness living alone with mobility problems in distress because he is embarrassed at the problems I had getting into the house, and it has reminded him that ‘it wouldn’t have happened if my wife was here’. Where do I start?
You will be pleased to hear that Mr Dinwoody was well when I left him, and after a long talk and a clarifying phone call with his son, we were able to arrive at the facts and I was able to get on with the job of medically assessing him and ensuring he was safe to stay at home.
Briefing locums for home visits
All GPs are thrown into demanding situations every day, but unlike the practice’s regular GPs, locums have many more factors that they are unfamiliar with. Lack of knowledge of local geography, or background knowledge of the patient’s condition and social circumstances, can make even a routine visit time-consuming for the locum and practice, and an ordeal for the patient. In other cases, this could lead to unnecessary hospital admissions and requests for repeat visits.
Many of the problems highlighted here could be overcome by some simple, brief preparation before any locum sets off on their visit. The checklist below is also embedded within the NASGP Practice Pack, provided free to GP practices by the NASGP, all accessible from a smartphone.
Even with use of the checklist, visit requests for patients known to be near the end of their life or in palliative care, should remain a special case where relationship continuity is often key.
Having a ‘stranger’ involved at this sensitive stage can be upsetting to the patient and their carers. It should also be remembered that issuing a death certificate can be complicated if the last attending doctor is a locum who is not regularly based at your practice, leading to upsetting delay for the bereaved and a headache for the practice.
Other than just the acute reason for the visit, it is of enormous value to understand more of the context of the visit that may not be clear in the usual patient notes, and this can be done very quickly by one of the practice’s GPs, or another member of staff, who may have some knowledge of the patient.
NASGP has produced a popular downloadable template for practice staff receiving or reviewing visit requests to complete to help visits go as smoothly as possible, and many of those are listed here.
About the visit request
- What was the reason given?
- Who asked for the visit (record their role and contact details)?
Palliative care or end-of-life care
- Is the patient in palliative care? If yes: please give details/contacts.
- Is the patient known to be nearing the end of their life? If yes: what has been discussed with the patient and have their wishes been recorded?
- Is there a DNA CPR in place?
The patient’s general condition
This is about finding out what the patient is usually like via ‘soft knowledge’ that may not be recorded in a patient’s notes:
- Any comments that can be made about the patient’s usual mental state.
- Any comments on the patient’s usual level of mobility, eg ‘She has been wheelchair bound for years.’
- Does the patient live alone?
- Does the practice know of any family members involved in caring? (If there are family members, give contact details.)
- Is there a care package in place? (It is useful to state if there isn’t; if there is, please give details and contacts.)
Safety and security
- Are practice staff aware of any safety issues associated with the location of the patient’s home, from the patient themselves or from any family members or pets that might be present?
Finding the patient’s home
- Are there any helpful directions? (Even with satnav it can be difficult to locate an address, simple tips can save time, e.g. it’s a large tower block; it’s opposite the supermarket.)
Accessing the patient’s home
- Will anyone else be present during the visit?
- Can the patient, or somebody else, answer the door? If not: how will the doctor get into the patient’s home?
Equip the GP with a list of useful contacts
- Direct access number for the practice (remains accessible even if the main patient line is closed).
- Medical admissions
- Care of elderly admissions
- Surgical admissions
Author : Dr Richard Fieldhouse is a sessional GP in West Sussex and chairman of the National Association of Sessional GPs.