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It’s likely that you have already seen the letter from NHS England to all GP practices and Primary Care Networks, asking them to pro-actively monitor care home residents for signs of deterioration.

The new request, in response to the growing concern of COVID-19 in care homes, aims to minimize the impact on older people in care settings.

Proactive monitoring of all care home residents

As we know, GPs supporting older people in care homes is not a new concept. The current norm involves GPs reacting to requests for help from care homes when a patient becomes unwell. The new ask is for GPs to implement a proactive model where patients are directly monitored for signs of deterioration.

This means that a huge volume of patients will need to be assessed. Taking Folkestone as an example, there are 41 residential elderly care, mental health or learning disability homes and five nursing homes, with a potential total of 962 residents. This is a huge task for GPs and PCNs.

If this new requirement affects your practice, group or network, McCartney Healthcare Associates has developed an innovative solution to help you to proactively support a high volume of patients without a large demand on your limited resources.

The NHS England model

The NHS England letter describes a model to provide a consistent national approach. This model should be adopted if your practice or network does not already have systems in place to monitor care home residents.  

The suggested model has three strands:

-Weekly check ins to review patients who are identified as a clinical priority for assessment and care.

-Personalised care and support plans for all care home residents.

-Pharmacy and medication support to care homes

The challenge ahead for GPs and Primary Care Networks

The challenge is to identify the patients that are a clinical priority and determine how you can support those patients with a weekly remote check in. The problem lies in finding a way to do this without creating a large strain on your resources.

Remote check ins are recommended in all but the most critical cases where patients are seriously ill and need of active care support.

An ideal solution

The solution lies in assessing the risk level of all care home patients using a bespoke tool. This will define the level of risk for each patient and allow you to actively monitor the most high-risk tier.

This risk-stratification tool uses existing parameters to indicate the status of a person’s health. These measures would determine if a patient is well, deteriorating or improving. The parameters would include those used NEWS2, the national early warning score, Frailty Scores and Activities of Daily Living (ADL). Indicators would include a patient’s ability to communicate, socialise, eat and drink.

Patients falling below certain criteria can be placed onto a risk log and can be monitored by a designated Project Coordinator.

How the risk stratification approach works

Baseline assessments

Initially, care homes complete a baseline assessment of all patients in their care. The results are added to a patient’s EMIS record and placed on a risk log database. The database would be held at practice or a Primary Care Network level depending on the intended population to be covered.

This baseline will identify all patients that are a clinical priority. If this is cross-referenced with respiratory assessment parameters, it will establish those most at risk of Covid-19, patients that require testing, and patients who should be given further consideration for active support.

All patients identified as a priority receive further remote assessment from a GP or Advanced Care Practitioner. This professional can then develop an appropriate care plan and if needed, address the sensitive issue of advanced care planning.

Active monitoring

The patients who have been assessed as a clinical priority will continue to be monitored by care home staff daily. Any change is reported to the care home support team. This team will monitor the condition of patients and refer any that need face to face assessment to the Home Visiting Service. Where necessary, cases will be passed to a Pharmacy Practitioner for medication advice and review.

This active monitoring will be for a small, manageable number of patients, rather than the full cohort of patients across your care homes which could be around 1,000.

The system is reliant on care homes being supportive. At this difficult time, care homes are working hard to protect lives and are likely to welcome a model that will help them to do this.

Capturing patient data

Baseline and monitoring data is captured in a bespoke template, resulting in a live database of all patients’ current health status. This assists the care home and the monitoring team and quickly identifies new patients who meet the clinical priority criteria.

The solution is potentially more thorough than the NHS England model suggests because it provides a real-time view of the health of care home residents rather than a weekly assessment of deterioration. It is a truly proactive model that will help you to identify, manage and refer care home patients.

Proof that this solution is effective

This solution was used as part of a winter pressures pilot project. The aim was to reduce admissions to hospital. The project particularly focused on reducing zero- or one-day lengths of stay when care home staff suspected that patients had Sepsis.

The pilot was carried out across 28 care homes for Dudley Clinical Commissioning Group in the West Midlands. It ran between 18 December 2015 and January 31, 2016. In this 45-day period, the following results were achieved:

Total Interventions
133 New Interventions
19 Place on Risk Log
152 Total
15 999 Ambulance
0 Sent to Hospital
Inbound Calls
41 Via 111
92 Via Direct Line from RCH
Lowest & Highest = Dates
2 24th December 2015
22 1st January 2016

The successful project was extended to 5 April 2016.

How to access this solution

McCartney Healthcare Associates can help you to manage this new demand on your workload by helping you to design and implement a version of this model tailored to your caseload. We have a model ready to implement, and we can get you up and running within a few days.

We can provide remote support, and the system can be integrated with your clinical system and your current COVID-19 assessment template. We can help you to determine the best way to resource this additional responsibility without creating additional resource implications.

The more quickly you can implement a solution, the more lives can be saved.

Get in touch

To find out more and to start developing your solution, contact us today. We can have your system up and running within a few days, helping you to save lives in your region.


Letter sent from NHS England to GP practices and Primary Care Networks on 1 May 2020: