Tag: ACP

by Dr Paul Baughan. GP, Dollar Health Centre. National Clinical Lead for Palliative Care with Living Well in Communities, Healthcare Improvement Scotland

Healthcare Improvement Scotland is temporarily refocusing improvement resource to support work aligned with COVID-19 resilience. The primary care team in the ihub and LWiC have been working together to pull together some resources to help respond to increased service demand. The topics will include developing Hospital at Home services, using NHS Near Me, and proactive Anticipatory Care Planning. More information will be available soon.

People living with frailty are among the most vulnerable to severe illness and death from the COVID-19 infection, and so the activities which teams have undertaken to identify this group, and then to develop anticipatory care plans will likely prove to be extremely helpful.

Some practices may be able to use the information within their frailty registers in a proactive way to target support for people with frailty.  The practice that I work in is planning the following activities:

• Contacting people with severe frailty by phone to check that they understand what they need to do to minimise their risk of infection, and know how and where to seek advice if they have symptoms. We have produced a template for proactive COVID-19 – frailty work.
• Asking people with severe frailty if they are happy to have a Key Information Summary (KIS), explaining that this will allow NHS24 to be aware of their medical conditions should they need to phone for help or advice.
• Checking that any next of kin and power of attorney information is up to date on the KIS.
• Adding a note on the KIS that this person has been identified through the electronic frailty index (eFI) as living with frailty.

Whilst the above activities fall short of a comprehensive ‘anticipatory care plan’, they will prove to be helpful should someone with frailty require to call NHS 24, or need help from a provider of unscheduled care.

These phone calls could be undertaken by several different members of the primary care team, and could even be undertaken by a well staff member with access to an NHS laptop who is self-isolating at home.

Please do not hesitate to contact a member of the team on hcis.livingwell@nhs.net if you have any questions about the frailty collaborative in the context of COVID-19.