Dr Amy Heskett is a Speciality Doctor working in a Community Geriatrics team within West Kent called the Home Treatment Service. This team works alongside paramedics, GPs and district nurses to prevent unnecessary hospital admissions for people with frailty, multiple comorbidities, caring responsibilities or as part of end of life care. The home visits use bedside testing and a multi-disciplinary approach to provide management of many acute medical presentations in a home-setting. The development of these holistic plans requires a creative approach and the experiences often generate tweets @mrsapea and blogs at communitydoctoramy.wordpress.com
The bag I take on every home visit has numerous pockets with endless equipment and forms required at my fingertips. I clip the same badges and emergency kit to myself at the start of every shift and I take this order and strict routine with me into environments over which I have little control. It is within this mix of structure and chaos that the creativity to manage conditions and sometimes crises within a community setting arises.
Publications and conferences have explained the importance of avoiding unnecessary hospital admissions (especially for those with frailty) and commissioners require data on the number we have achieved. However, I could find no written guidance on the practicalities of achieving this and so I just absorbed advice as I went along. The following list grew from feedback received from paramedics, carers, patients, District Nurses and GPs.
F.O.R.E.S.T FACTORS: Frailty identified, but which situations can be managed at home?
An assessment, development of a management plan and initiation of treatment in a home environment is an intense encounter that should have time invested into it. People with frailty can deteriorate quickly and therefore need to be managed in the most appropriate setting and have their expectations set correctly. If any part of FOREST fails then admission needs to be arranged urgently or the checklist below can be used to navigate candid discussions to allowed informed choice. Stumbling through a FOREST can indicate that further progression on a community-based path may not be a walk in the park.
Functional Level: The joy of community-based medicine is the focus on maintaining (and ideally enhancing) a person’s abilities. The minimum level of mobility required for safe management at home is to be able to stand and step to allow transfer to a commode and monitoring of pressure areas. Alternatively the person’s baseline level could be that they are bed-bound and they should have in place (or quick arrangement should be made to supply) pressure-relieving equipment. The person may be able to access food, drinks and essential medications at regular intervals, if not then there should be quick plans made for family, neighbours, carers, healthcare professionals (often a combination) to provide these.
Observations: Vital signs should be within normal limits or be within the range recorded for the individual previously. Abnormal observations should have a quickly sourced cause, a plan to correct and to review response promptly. Combinations of changes in physiology make me more inclined to suggest hospital-based care.
Review: When and who needs to see this person to ensure that the management plan initiated is having a positive effect? Paramedics will often refer to our service and state that they have identified a medical problem, initiated a plan and require us to follow-up the response. My work is a strange combination of lone-working with periods of intense team working and I often completely rely on the feedback and advice I receive from District Nurses who are able to look at the nursing needs within the management plan initiated. Families and carers need to know when we are going to see the person at the centre of the plans again and what the trajectory of the illness may be, within this I am open about possibilities of deterioration and discuss what we should do if this were to happen.
Examination: Our team is fortunate; we have access to a lot of portable bedside testing. However, clinical examination remains the main source of information and admission is necessitated if radiological examination is required. For example, if acute confusion can be explained adequately by history, examination, blood tests, bedside testing and collateral history then it may be possible to avoid radiological investigation but this needs to be explored for each case.
Safety And Sores: Consider if this is a safe place for the patient to stay and for other staff members to subsequently visit. Alerts can be placed on IT systems to indicate that 2 members of staff are required or details of keysafes and next of kin to allow access can be identified. A recent record edited by our team explained that there were numerous steep staircases to find the room in which the person was ensconced and a list of equipment already stashed in the rafters avoided heavy loads! We deal with lots of cluttered rooms and respect the choices that people have made when living at home, however a frank discussion about the ability of teams to provide safe manual handling may need to be explained and compromised upon. Check pressure areas, carry barrier cream, advise mobility and order kit to enable this and prevent pressure sores.
Timely: The physiology of those with frailty is already compromised and they may present insidiously to healthcare professionals and need quick access to treatments or discussion of options. When referred a patient I am honest about the time-frame I can provide. Many families have reached a crossroads in the care required and therefore trust begins with honest discussion of capabilities.
ABCD: A Before Closing Door Checklist:
A: ASK people what they want. What are their goals, what are their fears and would they consider hospital admission if required. What level of function is necessary to achieve activities that allow a quality of life important at their current stage of life. Gather the views of family, friends and carers if given consent to do so. Once the target is understood everyone needs to work towards this as a team and if it is not achievable then both sides need to plan how to alter current management or what compromises would be considered.
B: BOWELS and BASICS of course it is pure chance that this is number 2 in the list! I have walked into situations where it is not clear why a person with frailty has suddenly experienced a reduced mobility level and the plan to concentrate on basics has seemed hopeless. Fluids, nutrition, company and bowel management have often resulted in great leaps forward.
C: CONFUSION Is this old or new? Get a collateral. Quite often when I cannot get a situation straight in my mind I have to remind myself to complete a delirium screen and then all becomes clearer to me! Labeling and explaining delirium can help carers and family understand the cause for the current situation and also the seriousness of the condition.
D: DECISIONS the hardest of these to understand (for surrounding family and healthcare professionals trying to provide help) are choices that go against medical or safety advice. The most important assessment to make is that of mental capacity and the hardest thing to convey to others surrounding the person is that the decision should be respected if they have capacity to make it. People who go against advice need regular conversations to see that they are still happy with their choice and to provide different options that may assist their current situation. People who are clear on their wishes often have great strength and function fantastically even if not in line with medical advice. Teams get frustrated, they want to help, but these patients often make me think out of the box and develop skills required to do so. If walking into a point of crisis at a time when a person does not have capacity it is advisable to search and ask family if any advance decisions are in place that could help direct decision-making.
E: EVERYONE tell everyone the plan after asking the patient what you can share. I upload care plans onto every IT system I have access to, I put alerts on systems to state that an admission avoidance plan is in place and what teams are involved and happy to support. I ring and speak to family and explain what plans are in place and why that has been done; they often need time to consider the decision not to admit and come to terms with the fact that the person at the centre of the plans may continue to have a physical decline. Hospital is a default option and family need time to assimilate the information that the risks may be higher at this stage of the person’s life. Families need regular support and reassurance, without establishing trust the home visit will be wasted and an admission will occur after you leave. I email and ring GPs (depending on their preference), I let paramedics know the result of their decision not to transfer to hospital. If all else fails I highlight our team’s contact details on care plans and DNAR forms left in the home with permission. Spending time communicating kindly, but candidly and investing time on the first home visit means that subsequent admissions may be averted and subsequent contacts are smoother and briefer.
F: FALLS assess risk at every visit and correct modifiable factors. Think bones, think movement and think how to allay fear.
G: GET OUT and socialise. I refer to voluntary groups, day centres and befriending groups continually. Providing carers a break within their day can be a lifeline. Socialising can improve physical function and provide support for difficult decisions that may need to be made about the future.
H: HELP OTHERs both within and outside your team. Leave care plans or clues within the home that would have helped you in an emergency or out of hours. Leave contact numbers and kit required for next stage of treatment (drugs, equipment, drug charts). Community medicine works on the exchange of information and favours. Teams that I have helped have passed that assistance back to me at times when our team has been stretched. My phone is filled with numbers that have provided invaluable advice.