Home visits can be more challenging than practice-based consultations for a number of reasons; more patients are likely to present with serious illnesses, the home setting is not designed for consulting, there is limited access to patient medical records, and locums generally have no previous knowledge of, or existing relationship with, the patient.
A key method in coping with the challenges and minimising risks associated with home visits is to ensure that you are well prepared, before you set off.
Know the local area
You should always check whether the practice you are working for has a locum pack, as this is likely to include useful information about local services and relevant documents that you may require, such as community DVT pathways, palliative care charts, DNACPR forms and local prescribing formularies.
Know where you’re going
As home visits can be very time consuming (you may often spend longer travelling than actually seeing patients), it is important to know in advance of each locum session exactly how many you will be expected to perform.
Allowing up to one hour per home visit, ensuring you are confident with directions and having any key codes that may be required for access will help to avoid feeling stressed when gaining entry or unnecessarily time pressured during the consultation, which could potentially lead to mistakes being made.
Know who you will be visiting and why
Obtaining as much information about the patient as possible is vital. Who requested the visit? What reason was given for the request? Does the patient lack capacity? Is a chaperone required? Are any third parties likely to be present?
If the visit was requested by a third party, it is important that you identify their concerns to ensure that you address these fully. If in doubt, it can be helpful to call and speak to them before visiting and, if possible, try to attend when they can also be present.
It is unsatisfactory for all parties to discover after a home visit that the main concerns were not addressed, and this can also create fertile ground for adverse events.
If you do not have mobile access to the practice computer system then you should take an appropriate record summary printout with you to the consultation. However, it is important that you ensure you comply with data security and information governance policies.
Know what equipment you will need
You should check a full set of observations for most patients requiring home visits. As well as providing objective data, it can also help to identify if their condition is more serious than you had initially appreciated. This is an important step – which can be done in just one or two minutes - that can help to avoid adverse events.
You should therefore ensure that you are well prepared with all necessary equipment. In addition to your stethoscope and sphygmomanometer, you may like to take a tympanic thermometer, blood glucose meter, PFR meter and a pulse oximeter.
There are also many diagnostic, risk scoring, and sepsis screening tools now available which can help to support your management plan in the event that you are required to justify this (for example, if you have to make a hospital admission or if you later receive a complaint about the care you provided).
Know the importance of good record keeping
Good medical records play a key role in the delivery of quality care and will also provide the basis of your defence if a medicolegal matter arises following a consultation.
You should always make comprehensive notes of your assessment including what you discussed and with whom, a clear follow up plan and safety netting advice, and enter your notes in the practice’s system without delay.
Know what support you have available
Home visits often involve multifactorial and complex issues and if you are in any doubt about what you should do in a certain situation then you should not hesitate to seek appropriate advice. This may include contacting an experienced partner at the practice, a secondary care colleague or your medical defence organisation.
If you feel that a consultation is not going as well as you would have liked, take a moment to check with the patient and others present to ensure that everyone agrees with the management plan you have discussed. If not, then you still have an opportunity to rectify this.
Know the red flags
Prescribing can be a particularly high-risk area for locums performing home visits, as delays can lead to serious adverse events. When prescribing, you should always follow local formularies and discuss with the patient how they will obtain the medication. If you are uncertain of any drugs or dosages, it is important to take the time to check a prescribing reference.
Similarly, it is vital for locums to be familiar with local mental health services and safeguarding policies, and how to make routine and urgent referrals. Capacity is also particularly important to assess and document (especially so when patients refuse treatment or hospital admission, as commonly encountered on home visits).
Palliative care consultations can also be a high-risk area as they often take significantly longer than other consultations. You should always allow for this and take care not to appear hurried as the patient and their family will likely be very anxious and distressed.
Instead, it is important to spend the time to address their concerns empathically. When symptom relieving medications are required, you should consult your local palliative care guidelines and take steps to ensure that these can be obtained in a timely way.
In summary, working as a locum performing home visits can be challenging, busy and potentially high-risk. However, as long as you are prepared for this, familiarise yourself with local guidelines, inform your MDO of the work you will be undertaking and know what support you have available, it can be a satisfying change from surgery based consultations in general practice.
- Dr John McGuire is a medico-legal adviser at Medical Protection. Before joining Medical Protection he worked as a sessional GP for 10 years and performed home visits during both scheduled and unscheduled care periods.