General Practitioners Committee Wales General practitioner

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Care homes direct enhanced services (DES) FAQ

This guidance is based on questions submitted by members of GPC Wales and/or Local Medical Committees regarding the Care Homes Directed Enhanced Service (DES) agreed as part of the 2017/18 Welsh GP contract.

It is intended that this will be a ‘working document’ which will be updated as other issues and uncertainties arise.

The specification for the DES and regulations can be found on the Welsh Government’s GMS contract website.

 

  • What defines a Care Home?

    For the purposes of this Act, an establishment is a care home if it provides accommodation together with nursing or personal care, for any of the following persons. They are:

    a) persons who are ill or have been ill
    b) persons who have or have had a mental disorder
    c) persons who are disabled or infirm
    d) persons who are or have been dependant on alcohol or drugs

    But an establishment is not a care home if it is:

    a) an independent hospital
    b) an independent clinic
    c) a children’s home

    Around Wales there are many different models of care premises some of which are registered as “Private Hospitals”. Those that are considered as such are inspected by Healthcare Inspectorate Wales, not Care Standards Inspectorate Wales.

    View a list of homes registered as independent hospitals (Healthcare Inspectorate Wales)

    Premises listed on the HIW register referenced above are not included in the DES agreement.

  • Patients with Learning Difficulties

    It is not expected that residents with Learning Disabilities come under both the Care Homes DES and the Learning Disability DES. Practices/clusters should decide which applies, depending on what is most appropriate for the resident.

    This does not alter the principle regarding private hospitals; their patients do not fall under the Care Homes DES.


    (a) A learning disability residential unit / home registered with HIW

    If a learning disability residential unit / home is registered with Healthcare Inspectorate Wales as an independent hospital, the learning disability home is not classed as a care home.

    Health Boards will need to clarify with Healthcare Inspectorate Wales whether the learning disability unit / home is registered as an independent hospital. The HIW website indicates the inspections they have undertaken in relation to learning disability residential units.

    If the GP practice needs to undertake an annual health check, this will be covered through the Learning Disability DES.


    (b) Residents with a learning disability living in a care home registered with CSSIW

    For residents with a learning disability who are elderly, less mobile with an expectation for home input, and living in a care home where the higher percentage of residents are elderly and less mobile, it would be appropriate for their care to be covered through the Care Homes DES. If required, the practice / LMC can agree with the health board.

    For residents with a learning disability living in a care home who are younger and more mobile with an expectation they would usually be expected to attend the surgery, it would be appropriate for their additional care to be covered through the Learning Disability DES. If required, the practice / LMC can agree with the health board.

  • Annual Resident Reviews: format and timings

    The wording of the agreement with respect to the annual review could potentially cause a lot of separate assessments with unintended workload on practices.

    Welsh Government have agreed to request flexibility on this to allow practices/clusters to approach these reviews in a more collective way, as this was not foreseen.

    The total minimum number of reviews is agreed to be 3: i.e. one Initial, One Annual and one Medication. As the medication review can be carried out by a pharmacists this leaves a minimum of two to be carried out by the practice/cluster.

    Welsh Government are clear that they expect the medication review to be a separate one.

    The format of the annual review is decided by the practice/cluster, if needed with LMC discussion with the Health Board.

    With regard to timings, the statement below has been circulated to Heads of Primary Care by Welsh Government:

    The Care Homes DES, paragraph 19, sets out the requirement for each resident to have a comprehensive annual review undertaken within 4 weeks of the anniversary of the day the resident moved into the care home. Some GPs have indicated that for some longer term residents it can be difficult to identify the exact date the resident moved into the care home and so have undertaken their annual reviews in batches to optimise GP time. Given the need to ensure a pragmatic operational approach, it is proposed for longer term residents (say, residents over 12 months) that the practice can start the annual resident review at a month determined by the practice and for this point to be the annual review date / anniversary date for future years.

  • Coding and claiming

    There is no READ code to identify a post unscheduled care review. NWIS advise it will be some time before health boards are able to request changes to the READ codes.

    Practices will need to implement their own systems to ensure claims are evidence based which may include using existing READ codes and a supplementary system to ensure the post unscheduled care review has been done. This will likely mean that free text will have to be used.

  • Availability of staff

    Welsh Government have clarified that the practice and/or cluster is NOT expected to supply all the staff to meet the requirements of the agreement. A multi-disciplinary team approach using the best available professional for patient care, with a facilitative approach from Health Boards, has been agreed. The practice/cluster is expected to oversee and drive forward care, but not to provide all the staffing. This may include practice, cluster and Health Board employed professionals.

    GPC Wales and Welsh Government want to move away from a culture of defining the practice enhanced services in terms of which professional sees the patient, towards one of “who is best placed” with the practice taking overall responsibility to ensure appropriate referrals are made.

    Practices cannot be penalised in payment or other terms if appropriate professionals are not made available by the LHB.

    As described in paragraphs 7 and 14 of the specification, the multi-professional team can include, for example, clinical pharmacists, dieticians, optometrists, physiotherapists, chiropodists, podiatrists. There is no expectation the GP will personally deliver all aspects of the holistic assessment, but will be responsible for recommending the assessment and appropriate referral.

    For example, where the GP highlights through the Initial Resident Review or the Annual Resident Review or the clinical review that the resident requires say a falls assessment; or podiatrist; or community dentist; or community audiologist or osteoporosis risk assessment, the GP is not expected to undertake this work.

    Annex E of the DES set out the role of health boards in coordinating the availability of community based services / professionals.

  • What does the DES payment cover?

    As described in paragraph 12, the Initial Resident Review or the Annual Resident Review and a minimum of one clinical review (further reviews to be undertaken as clinically appropriate) will be undertaken by GP practice / cluster staff.

    The £270 payment per resident will cover the cost of the GP practice:

    • undertaking these reviews;
    • monitoring the provision of care;
    • undertaking post unscheduled care reviews as required;
    • completing Special Patient Notes;
    • completing an annual report;
    • recommending the assessment and appropriate referral in relation to the multidisciplinary team.
  • Clusters

    Practices/clusters are free to decide the best way forward to deliver care under the agreement with regard to the use of cluster resource.

    The expectation in keeping with the whole cluster ethos is that the clusters decide this as the best way forward, as not mandated by the health board.

  • Medication reviews

    In light of significant investment, both Welsh Government and GPC Wales strongly believe in the provision of pharmacists in roles where they are best placed to deliver for patients, and relieve unnecessary workload for GPs and practices. This direction is taken forward in the Care Homes DES, however it is not the intention to specify that the professional who undertakes the medication review cannot be a GP.

    As Health Boards should be providing pharmacists for these roles, we would expect this provision to be in place.

    It is not intended that the agreement be prescriptive in terms of who performs the review; rather that it facilitates prudent healthcare as far as possible leaving the oversight and responsibility to the GP and practice wherever possible. This is in much the same way as a secondary care department would operate.

    The following statement has been put out to Heads of Primary Care by Welsh Government, indicating that a GP can indeed carry out the medication review if needed;

    The Care Homes DES, paragraph 17, highlights that a GP employed pharmacist, or cluster based health board employed pharmacist, or community pharmacist providing services to the relevant care homes will undertake at least one medication review, regarding polypharmacy, antipsychotic prescribing and other high risk medication. Some GPs have asked that if necessary are they able to undertake the medication reviews. The intention of this paragraph was to clarify the role of pharmacists in undertaking a med review; the intention is not to exclude GPs from undertaking a med review is they so wish. Accordingly, it is proposed that a GP can undertake a med review if they so wish.

     

    Can a community pharmacist carry out the medication review?

    Yes, this is possible, for instance in respect to a commercial pharmacist who does dosette boxes for the home.

  • Temporary residents and short term placements

    The issue of ensuring the work carried out for temporary or short term residents is covered explicitly in the agreement.

    For a Temporary Resident, if a resident has had an initial assessment, the claim would fall into point 28 of the specification below i.e. “up to six months.”

    The death of a resident is covered under point 27 of the specification. There is no lower limit in this condition and includes patients who die within the year.

    The relevant paragraphs are listed below for clarity:

    27. Where the death of a resident occurs during the year, the practice is able to claim the full payment for that year as long as the Initial Resident Review has been completed. If not, the practice will not be able to claim a payment.

    28. If a resident resides in a care home up to 6 months of the relevant financial year the practice will receive 50% (£135) of the annual payment.

    29. If a resident resides in a care home up to 9 months of the relevant financial year the practice will receive 75% (£202.50) of the annual payment.

    30. If a resident resides in a care home for over 9 months of the relevant financial year the practice will receive 100% of the annual payment.

  • Notice and moving across from an existing LES

    With regard to change over, Health Boards must provide the DES from April 1 2017.

    Period of notice is usually 3 months but can be less by agreement, if a practice is withdrawing on resilience grounds.

  • What happens if hospital discharges or patient notes are not received within the stated period?

    Practices/Clusters should not be penalised by factors outside of their control, such as delay in discharge information or records being transferred.

  • Claiming for deceased patients: Open Exeter Issue

    Practice managers have raised that there is an issue when trying to make claims using open Exeter once a death has been entered onto the system.

    In accordance with advice received from the NHS Wales Shared Services Partnership, as long as the practice claims for the patient on the last day they were registered on their list, then the system should validate the patient at that point and allow the claim.