Do I need to do home visits?
As with the reduction in face to face contacts for patients attending the practice, the need for a home visit should be carefully assessed and should only be done if:
- telephone or video consulting cannot be done, or
- a physical examination is considered essential and the patient is unable to attend the practice/hub.
If you have sufficient infection control procedures in place, then you might request patients come to the hub or practice rather than performing a home visit. If you have established a dedicated home visiting team, then that team could attend the home.
All home visit requests should be triaged in the same way as requests for ambulatory patients – with remote assessment in the first instance.
You must wear appropriate PPE if attending the home. As in all situations during the pandemic, guidance on infection control should be followed, including handwashing.
Home-visiting clinicians should ensure that ‘home visit’ bags contain necessary additional PPE and clinical waste bags. They may also provide equipment at the visit to enable patients to take their own observations or with the help of those living with them. This equipment should then be appropriately decontaminated when returning to the practice.
If you identify COVID-19 during a home visit
If symptoms of COVID-19 are identified during a home visit, staff should ensure they have the patient or carer’s telephone number.
If a physical examination is not required staff should then withdraw from the room, close the door and wash hands thoroughly with soap and water. PPE should have been worn in advance of entering the house. Further communication should be via telephone wherever possible.
NICE have prepared guidance on when to consider hospital admission for patients with symptoms of COVID-19. Health Protection Scotland have prepared equivalent guidance. If an ambulance is required, the call handler should be informed of the risk of COVID-19.
Do I need to visit care homes?
Populations in care homes will include patients requiring routine primary care input and patients requiring urgent assessment for non-COVID-19 related illness.
As with any consultation during the pandemic, any regular care home ward rounds and requested assessments should use remote consultations wherever possible.
Care home staff should be able to facilitate this by providing patient observations, including temperature, blood pressure and oxygen saturation levels.
Attendance of the patient at a hub or practice could be considered as an alternative, if in place and practical.
Where a visit is necessary, appropriate PPE should be used, as for all patient facing contact. As in all situations during the pandemic, guidance on infection control should be followed, including handwashing.
If symptoms of COVID-19 are identified during a care home visit, the local health protection team should be informed.
Welsh Government, health boards and GPC Wales negotiated a revised care homes enhanced service to refocus on the support needed during the Covid-19 pandemic. The revised service will roll over until renegotiated with GPC Wales.
The service provides for an initial resident review within 28 days of moving in, which can be done remotely, and an annual medication review which can be done by allied health professionals.
Engaged GP practices are responsible for undertaking a weekly ward round, which can be done remotely for infection control purposes in discussion with the care home.
GP practices engaged by a care home must offer a ‘bypass line’ telephone system during core hours so that care home staff can receive clinical advice. You can view the full service specification.
Advanced care planning
Advance care planning should be undertaken on an individual case-by-case basis remembering the principles of Good Medical Practice. Patients have a right not to engage if they so wish.
The BMA released a joint statement with RCGP and CQC on 1 April.
GPC Wales released a joint statement with RCGP.
When developing advanced care plans with patients, practices should adhere to some key principles:
- careful consideration needs to be given to which patients may specifically benefit from having these discussions at this time, based on relevant clinical factors
- all discussions must be tailored to the individual circumstances of the patient
- as part of advance care planning, it can be helpful to consider any anticipatory decisions about whether or not CPR should be attempted
- it is unacceptable for blanket decisions about advance care plans, and decisions about do not attempt cardiopulmonary resuscitation (DNACPR), to be applied to particular groups of people
- care needs to be taken when considering how patients are first contacted with a view to initiating advanced care planning discussions
- discussions need to be managed sensitively and compassionately, ensuring that patients understand why they have been contacted and what they are being invited to do - you could use our patient information leaflet
- when discussing the possible treatment options in the event of them becoming ill with COVID-19, it is important to be clear that decisions about access to intensive treatment will not be made on the basis of their age or disability - it should be made clear that every patient will be considered individually based on clinical factors, such as their physical ability to benefit from treatment provided in intensive care
- whilst patients should be encouraged to think about their wishes for future care and treatment, they must not be put under pressure to do so, or to reach a particular decision.
Patients with COVID-19 may deteriorate rapidly so it is helpful if advance care planning conversations have taken place beforehand in relation to the possibility of contracting COVID-19.
Patients at increased risk of severe illness from COVID-19 should be encouraged to consider having such conversations in advance.
We have created an advance care planning leaflet that you can give to patients to help explain their situation.
If there is no relevant advance care plan, discussions about plans for treatment escalation should take place very quickly if the person contracts COVID-19.
The NHS has some further guidance on advance care planning.
We have also produced guidance on DNACPR.
Palliative care in care homes
Principles to consider in palliative care:
- care should be provided remotely where possible
- the number of healthcare professionals visiting the care home should be minimised
- GP teams should be aware of local policies being developed in conjunction with their local palliative care teams and community pharmacy for supply of end of life care medicines
- GP teams should liaise with community services and specialist palliative care teams to coordinate multi-disciplinary team input
- GP teams should use existing 24/7 telephone access to specialist palliative care for support
- where a decision is made to withhold or withdraw some forms of treatment from patients, it is crucial that those patients still receive compassionate medical care, as far as possible in the circumstances - this should include symptom management and the best available end-of-life care.