Enhancing Anticipatory Care Records in GP Services for Nursing Homes
Improving the quantity and quality of shared anticipatory care records in GP services supporting care homes with nursing in South East London. Project focus on championing work, promoting information sharing platforms, and learning from transfers across care facilities. Detailed case studies illustrate the extension of GP services to care homes and the facilitation of care planning conversations.
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Presentation Transcript
Improving the quantity and quality of shared anticipatory care records from GP services supporting care homes with nursing Sharing our story from South East London
Our project team O Dr Emily Gibbs GP with QHS GP care home service, Southwark and CCG Clinical lead O Joanne Hare, CCG commissioner working as trained non clinical facilitator using Coordinate My Care to record personal care preferences O Peninsula/ Clover GP practice supporting care homes in Greenwich
Where did we focus? O General practices supporting care homes O Champion work in Southwark and Greenwich O Focus on how to support use of Co ordinate my care O Network across the geographies, linking with other projects with similar themes O Promote CMC platform to enable information sharing O Learning from transfers across care
What have we done? O Over 300 individual records and conversations through the facilitator in Greenwich O Creation of records needing review and publication from GP lead O 69 new records in Southwark. Records viewed frequently and updated at review opportunities such as MDT meetings, change in condition
Case study O Extension of GP service to residential care home of 20 beds O All new patient checks included review of care planning wishes including creation of CMC record O Support framework for residents without capacity to consent to record sharing O CMC alert sent to GP when contact with urgent care services O Contacts with frailty services when resident in A&E
Case study O GP practice identified lists of residents without CMC plans O Facilitator was given EMIS access to read and confirm details O Where gaps of information identified, more information gathered by speaking with care home O Facilitator called relatives to have care planning conversation O CMC record started and then GP lead reviewed and published record
What did we learn? O Residents and families have been disconnected over the last 18 months O Conversations are key O Working over telephone contact is challenging when having a conversation about frailty O Supporting sharing of information in best interest framework with good discussion and documentation
Tips and prompts O In context EMIS link shortcut direct to CMC platform O Updates can easily be made on this link O Records can be created through link O Subscribe button for each record created will send email alert when urgent care access record O CMC platform can store lists by care home address O Have a process to close records as part of death certification
