Handling an increase in demand for home visits during COVID-19

Some GP practices may be experiencing an increase in demand for home visits as a result of the COVID-19 outbreak. Medical Protection’s Dr Roger Palmer and Ceylan Simsek offer advice on managing this.

Triage is essential to maintaining a sustainable and equitable home visiting service (Photo: sturti/Getty Images)
Triage is essential to maintaining a sustainable and equitable home visiting service (Photo: sturti/Getty Images)

As part of the COVID-19 strategy, GP practices have adopted a ‘total triage’ model of care delivery. This has changed the way consultations are being conducted, with patients no longer encouraged to attend GP practices in person. Instead, telemedicine applications, and arranging a phone or a video call with the nurse or doctor are the new normal.1

Despite this, some GP practices are experiencing an increase in demand for home visits - due to normal demand for healthcare in the community on top of COVID-19. NHS England has also advised practices to use home visiting if vulnerable patients who are shielding require a face-to-face appointment.2

Prior to COVID-19 home visits were a method of providing both proactive and reactive personalised healthcare, but this came with efficiency challenges. Undoubtedly, any increase in demand for healthcare visits during the COVID-19 crisis will further impact on efficiency and raise a number of consultation issues.

Triage

NHS England has recommended that practices move immediately to total digital triage1 followed by remote management wherever possible and appropriate. This involves three-steps to manage healthcare requests:

  1. When patients make contact – using telephone and, preferably, online systems;
  2. When doing the triage – administrative assistants validating patient details and escalating urgent matters where necessary; before
  3. The clinician determines best way to assess the patient – this can be either by telemedicine, home visit or a face-to-face consultation.

Most appointments will be dealt with through telemedicine,3 either on the phone or via video call, without an exact appointment time being given. High-risk patients should be prioritised, with any patient being able to access urgent and essential routine care.

With regards to home visiting, there are practical considerations for the health and safety of both the doctor and the patient, especially during COVID-19. NHS England has provided updated guidance and standard operating procedures (SOP) around this.2

This encourages separation of face-to-face consultations for patients with COVID-19 symptoms and those without, giving different models for delivery dependent upon local needs and resources.

Home visits during the pandemic

As part of the SOP, GP practices have been advised by NHS England to put together a dedicated ‘COVID-19 free’ home-visiting team for patients who are shielded and therefore most vulnerable to complications.

This team should comprise of staff suitable to undertake the work, following appropriate advice from Public Health England or Occupational Health relevant to their own health needs, and should not have been exposed to another patient with COVID-19 symptoms.

Where separate home-visit teams are not possible, patients with COVID-19 or symptoms attributable to it, should be seen at the end of any visit schedule.

Home visits will continue to be requested by practice patients, whether shielding or not. There may also be greater demand for visits as patients seek to avoid social contact by leaving their property to attend appointments.

Practical considerations for home visits

Deciding who should receive a home visit for non-COVID-19 illnesses is unchanged, and triage is essential to maintaining a sustainable and equitable service.

Points to consider include:

  • Where a patient is shielding and a face-to-face consultation is advisable, then a home visit is likely to be appropriate unless a designated site is available for such assessments (and the patient able to safely travel and attend)
  • Where a patient requires a home visit for a non-COVID-19 illness, does the patient live in the same household as someone with symptoms of COVID-19? If not, then then pre-existing triage policies would apply and, where arranged, would follow the local process (either through a non-COVID-19 visiting team or earlier in a visit schedule to avoid cross-contamination)
  • Where a patient has, or lives with someone with COVID-19 symptoms, home visits will sometimes still be necessary in the community. Additional infection prevention and control measures will need to be taken.

Irrespective of whether a standard home visit is for existing or new medical conditions, or part of the COVID-19 response, factors to consider prior to any home visit include:

  • Whether appropriate triaging has been done to ensure a visit is necessary
  • Identifying the purpose of the visit
  • Arranging an appropriate time to visit; ideally offering a time frame rather than a set appointment time to ensure flexibility
  • Following local guidance and arrangements
  • Contacting the individual to understand the physical environment and making sure there is a way to wash hands prior or after the visit
  • Ensuring the home visiting team has appropriate personal protective equipment (PPE)4 and, if possible, team members have not directly treated COVID-19 patients.

Should a request for a home visit be considered unnecessary, the patient should be managed through telemedicine or redirected to the appropriate healthcare centre (practice or hot site, or arrangement for hospital admission). This should follow NICE guidance5 and local clinical referral pathways. Most patients will accept this, and patients should be informed of the rationale for this advice and the clinical benefit to them.

Where the home visit takes place, factors to consider include:

  • Enquiring about the current health of the patient and confirming whether anyone in the household has symptoms of, or has tested positive for, COVID-19
  • Keeping two metres or more away from household members, minimising the surfaces you touch and washing hands prior and immediately after the visit
  • Taking a ‘team’ approach to any visit, minimising the number of healthcare professionals visiting where possible
  • Ensuring staff attending are both protected and have the adequate PPE throughout and know what each other are doing.

If GPs require further advice, please contact your medical defence organisation.

  • Dr Roger Palmer is a medicolegal consultant and Ceylan Simsek is a case management assistant at Medical Protection

References

  1. NHS England. Advice on how to establish a remote ‘total triage’ model in general practice using online consultations. (Version 2; April 2020)
  2. NHS England. Guidance and standard operating procedures: General practice in the context of coronavirus (COVID-19) Version 2.1, 6 April 2020.
  3. Medical Protection. COVID-19 and remote consultations – how we can help. 16 March 2020.
  4. Public Health England, Section 7. Risk Assessment, in 'COVID-19 personal protective equipment (PPE)'. Update 12 April 2020.
  5. NICE. COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community. NICE guideline NG165. Last updated 23 April 2020.

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