Being skilled in home visits forms an essential part of general practice. Your GP posts should expose you to a number of home visits over the course of your training.
Some GPs consider home visits the most complex part of our clinical work for a variety of reasons. Assessing a patient in their home environment is a very different skill to assessing them in the comfort of your consultation room and by definition these patients are likely to be more complex, frail and vulnerable.
Every practice will differ in how house visits are undertaken and allocated to the different doctors. Familiarise yourself with your surgery visiting protocol from an early stage in your placement.
Discuss with your trainer, what is expected of you with regards to home visits. If it transpires that your surgery is a low visiting practice, then think about what other opportunities there are for house visits, for example a visiting session with the district nurse or emergency care practitioners.
If your training practice undertakes a large number of visits, ensure you are not expected to carry out more than your fair share in comparison to your colleagues.
Never undertake a visit blindly. There will be many factors that will have likely led to a visit request. Gather as much as information as you can. As the patient's GP, you are in the fortunate position of having access to the full medical record.
A mental 'pre-visit' checklist is useful to ensure you have a successful consultation. The following are useful to consider:
- Has the visit already been triaged by a colleague prior to visiting, e.g. the on call doctor or the day before? If so, have any useful notes been made? If you are still unclear about any aspect of the case, speak to the doctor who undertook the triage if you are able to.
- Are there any useful slot notes in the home visit filter where information has been added e.g 'patient feels out of sorts. Seen yesterday and no better.'
- Where has the request come from – the patient, their carer, the district nurse, a family member, nursing home staff? Assuming no triage has taken place, then consider speaking to the person who requested the visit and undertake some basic triage to establish if a visit is actually needed. The following outcomes may then apply – visit no longer needed, patient can actually come to the surgery, an urgent ambulance response is needed, another healthcare professional maybe best placed to deal with the problem, e.g district nurse or emergency care practitioner dealing with minor acute illness, or they may require a direct non-urgent admission to hospital.
If you feel a GP visit is required then think about the following:
- How many visits do you have to do? If you are expected to undertake more than one, think about the geography of them and plan your route and timings accordingly. Palliative visits are likely to take longer so factor this in to your schedule.
- It is crucial you familiarise yourself with the case if you do not know the patient. Read the last few entries (particularly if this is an ongoing problem), the problem list, medication list and any recent hospital correspondence. Are there any advanced care plans, emergency health care plans or do not attempt resuscitation orders in situ?
- Has the patient recently been in hospital? If so, are there any relevant discharge letters? If so, ensure you read them. They are likely to contain a relevant narrative of the patient's condition on discharge and appropriate investigations. Review any recent imaging and blood results.
- Check the alerts. Are there any key safes/key codes to be aware of or access issues? Are there any safety issues to be aware of, such as a history of violence or inappropriate behaviour to lone visiting healthcare professionals? Is this visit suitable for you?
- Ensure your doctor's bag is well stocked and if you feel you may require additional equipment from the triage or slot notes, then ensure you have this, for example a stool pot, urine dipsticks, peak flow etc.
Ensure you feel safe upon arrival. Introduce yourself to the patient. You may have already spoken to the patient, carer or family member on the phone, so this will be useful.
Explore the patient's environment. This will generally occur as soon as you walk in. Are there any obvious hazards, such as poor lighting or loose carpets? Is there a strong smell of smoke or alcohol? Does the home appear unkempt and of immediate concern?
The patient is likely to be in bed or on the sofa. They may appear more unwell then they actually are so approach the consultation like any other remaining objective.
Take a focussed history of the problem and explore the social circumstances. These are likely to be crucial in formulating your plan. For example, a housebound, widowed, acutely unwell elderly gentleman is unlikely to be able to collect a prescription.
There maybe many family members present, which can be intimidating. Do not be afraid to ask them to leave the room while you undertake your assessment. You may wish to keep one family member present.
Examine the patient. This maybe difficult depending on where the patient is located and what help you have to be able to manoeuvre the patient – this will likely be easier in a nursing home than a patient's own home. Obtain objective vital signs if relevant – blood pressure, pulse, oxygen saturations and temperature.
Formulate a safe management plan. This will vary depending on the patient and your assessment. You may need to involve family members and allied health care professionals. If external carers already attend, you may wish to write in the patient's handheld notes to communicate the outcome of your consultation.
You may need to write your instructions down if you feel the patient may struggle to remember the treatment discussed and safety netting advice. Bear in mind that you may need to be very specific about how you write down your safety netting and red flag symptoms.
If you feel an admission is necessary, how you prioritise this will depend on your assessment. If a 999 ambulance is required you may need to stay with the patient until the paramedic arrives.
GPs historically do not carry panic alarms unlike many other visiting healthcare professionals. GPs also rarely visit in pairs. Your safety however is top priority.
Always keep a mobile phone to hand. If at any time you feel unsafe, leave the house and share your concerns with your trainer / practice.
Return to surgery
Type up your notes in a timely manner to avoid forgetting any pertinent information. You may wish to review any imaging or blood work again that maybe relevant to your assessment.
If your plan included a prescription, then prioritise the generation of this so it can be collected or delivered depending on what you agreed with your patient. If you admitted the patient, and did not write a letter at the time, ensure you communicate your findings to the relevant hospital team. Speak to your trainer if you are unsure how to do this.
If a follow-up is planned, ensure this is booked accordingly by yourself or delegated to a team member who can arrange this on your behalf. This may be a telephone review, surgery review or further home visit.
- Dr Singh is a GP trainer in Northumberland