Setting up Over 75 Health Assessment Reviews

  1. Administration – Set Up

1.1 Stationary requirements

A5 window envelopes

Banker self seal window envelopes

Banker self seal envelopes

Large 2nd class stamps

Small 2nd class stamps

A4 Plain white paper

1.2 Templates

Set up templates – two templates will be needed under the heading of Elderly Health Assessment.

  • Template 1 – Appendix 1- Geriatric Monitor 1st letter, to be used when the initial letter is sent to patient with the questionnaire.
  • Template 2 – Appendix 2 – Elderly Health Assessments, to be completed by Practitioner who has carried out a visit on the patient

1.3 Pack sent to Patient – what do we send to patient?

  1. Over 75 health assessment letter (standard) – Appendix 3
  2. Health Questionnaire to be sent to patient (standard) to be completed and returned in – Appendix 4
  3. Elderly Health – patient information leaflet (practice personalised) – Appendix 5
  4. Reply paid envelope

1.4 Home Visit Pack– available to download from our website madeleypractice.co.uk elderly care.

Used by Practitioner when visiting patient in their home, made up of the following:-

  1. Patient Summary
  2. Print out of patient Questionnaire (completed by patients aged between 75 and84)
  3. Assessment check list
  4. Action points
  5. FRAT Assessment Tool – Staying Steady Leaflet
  6. Six Item Cognitive Impairment Test (6CIT)
  7. Screening Questions for Depression
  8. Patient health Questionnaire – PHQ9
  9. Fast alcohol screening test
  10. Audit screening test for positive response to FAST
  11. Useful Telephone Numbers – practice personalised
  12. Local/national, groups, clubs and societies –practice personalised
  13. Elderly health – patient information sheet same as 1.3.3
  14. Next of kin/carer consent form – practice personalised
  15. Council Tax discount form
  16. Attendance Allowance claim form
  17. Disabled Badge Parking claim form
  18. DNAR white form
  19. Lasting Powers of Attorney information sheet
  1. Who do we send the questionnaire to? - 75 to 84 year olds as at the 1/1/2013

2.1 Eligible Patients

Patients aged between 75 to 84 years of age as at the 1st January 2013 with the following exclusions:-

  1. Patients living in a Nursing/Residential Home
  2. Patients registered as housebound
  3. Patients coded with dementia.

2.2Generating List of Eligible Patients

Run a search based on the above criteria and exclusions. Print search off alphabetically – this way we can ensure questionnaires are sent to married couples at the same time.

3.Organising Letters to Patients

3.1From search sendletters out weekly to patients.

Practice to decide number to be sent out and may need to be adjusted if number of visits required gets behind.The project is expected to run for 20 months.

Pack to patient is as described in 1.3

3.2 Complete Template – Geriatric Monitor 1st letter, enter the date the letter to patient has been sent and save.Appendix 1

3.3 Complete Cost Monitoring spreadsheet, detailing number of administration hours, number of letters sent and any other appropriate costs see 7.1.

4.Receipt of Completed Questionnaires

4.1 Completed questionnaires should be directed to the Administrator overseeing the Health Assessments before they are scanned onto patient records.

  1. On receipt of Questionnaire – complete Template – Geriatric Monitor 1st Letter – appendix 1
  • Score the questionnaire
  • Enter the date of receipt and the questionnaire score as free text in numbers under Elderly at Risk prompt.
  • Enter details of Next of Kin and telephone number.
  1. On major alert screen of patients records, set up ICE – in case of emergency – name and telephone number from the bottom of the questionnaire.

4.2 Questionnaires can then be scanned onto patient’s medical records.

  1. Home Visit – who gets a home visit?

5.1 Patients who will automatically receive a home visit will be:-

  1. Patients aged between 75-84 as of 1st January 2013 who have scored 5 or above on the Tilburg questionnaire.
  2. Patients with dementia.
  3. Housebound patients.
  4. All patients aged over 85

5.2 Organising Home Visit

Code the home visit onto the Geriatric Monitor 1st letter template, home visit planned – Appendix 1, (must be coded even if patient refuses home visit but in the text type in patient refused home visit). Contact patient, preferably by telephone to organise suitable date and time for Practitioner to visit (for dementia patients this may have to be arranged with their next of kin/carer), advise patient visit will last for approximately one hour and that their next of kin or carer would be welcome to join the review. Confirm appointment in writing. – Appendix 6.

5.3Day of Home Visit

Ensure Practitioner is aware of home visit and that Practitioner has a ‘Visit Pack’ to take with them. Print outa clinical patient summary to be included in the ‘Visit Pack’ and a copy of the patient’s completed questionnaire if done.

5.4After Home Visit

Practitioner to return ‘Visit Pack’ to administrator and administrator to:-

  • replace any forms used ready for the next visit.
  • log on the cost spreadsheet number of Nurse hour’s for each visit – discuss as set cost and enter mileage .

5.5 Letter to Patient after Home Visit.

The GP or Practice Nurse may write to patient outlining action points from the visit and any referrals etc that have been made. A copy of this letter to go to co-ordinator and should be coded onto Geriatric Monitor 1st letter template –Appendix , to check if any follow up is needed as detailed below.

  1. Follow up

Administrator to follow up Attendance Allowance and/or Council Tax Rebate if patient has applied for these benefits from the Home Visit, to ensure they are in receipt of them.

At the end of each month carry out a search on patients who have been sent a questionnaire but have not returned it to the Practice.

  • Discuss with GP patients who have not returned questionnaire, GP to decide on
  • No follow up
  • Chase up by phone or
  • Arrange home visit

This contact is not recorded on the template.

Each quarter carry out a search for any new patients who have registered with the Practice aged 75 – 84 years old and add include them in the project

  1. Cost Monitoring

7.1 Costs need to be carefully monitored.

Set up ‘Cost Monitoring’ Spreadsheet – see example below.

  1. Audit
  1. Number of patients eligble to send questionnaires 75-84 years old
  2. Number of patients >85
  3. Number of patients with dementia
  4. Number of housebound
  5. Number of questionnaires sent
  6. Number of questionnaires received back
  7. Number of patients scoring 5 or above
  8. Number of home visits offered
  9. Number of home visits carried out
  10. Number of GP letters sent to patient after visit
  11. Drugs BDZ/antipsychotic/NSAID/diuretic/ACEi/>4
  12. Lifestyle Number of patients who smoke and alcohol intake >14 units for females and >21 units for males
  13. DispensingCompliance Problem/have nomads/need nomads
  14. Social

Attendance Allowance / Blue Badge / Council Tax
Have
Referred For
  1. Referrals to
  2. Falls clinic
  3. Physio
  4. OT
  5. Chiropody
  6. Social Worker
  7. Geriatrican
  8. Psychogeriatrician/memory clinic
  9. Dietetics
  10. Speech Therapy
  11. Safety check fire/police
  12. CAB
  1. FRAT score >2
  2. 6CIT score > 8
  3. PHQ9 score 0-4 none, 5-9 mild , 10-14 moderate, 15-19 moderately severe,

20-27 severe.

  1. Number of patients received flu vaccination last 12 months
  2. Number of patients received pneumonia vaccination ever.

PCT to audit A&E attendances and acute admissions.

Appendix 1

Appendix 2

Appendix 2

Appendix 2

Appendix 2

Appendix 2

Appendix 2

Appendix 3

Dr Christopher G Oleshko
Dr Barry A Edwards
Dr Sarah L Gear /

Moss Lane Surgery

Madeley
CREWE
Cheshire
CW3 9NQ
Telephone: (01782) 750274
Fax: (01782) 751835

CGO/SJA

~[Today...]

~[Title] ~[Calling Name] ~[Surname]

~[Patient Address Line 1]

~[Patient Address Line 2]

~[Patient Address Line 3]

~[Patient Address Line 4]

~[Post Code]

Over 75 Health Assessment Questionnaire

Dear ~[Title] ~[Surname]

I am writing to ask for your help.

We want to identify the social and medical needs of our older patients and offer support where appropriate. Your answers are important not just for yourself, but also for other patients so we can address local issues.

Please complete the enclosed questionnaire and return it to me at the Surgery in the enclosed stamped addressed envelope. Underline or circle your answer to each of the fifteen questions. Below the questions is a list of issues for which we can provide further information on if requested. It should take you no more than two minutes. Ask a friend or relative to help you if necessary.

An ‘Elderly Health’ – patient information sheet is enclosed.

On receipt of your questionnaire we use a scoring system to identify those patients for whom we feel a home visit from the Surgery is required.

The project is funded by Madeley Practice Patients Funds and The Bishop Stamer Fund. If successful it is hoped that it can be extended to other residents in the Newcastle area.

If you do have any questions or difficulties filling in the questionnaire please contact Dr Oleshko or Sara Apa at the Surgery.

Thank you for your help.

Yours sincerely

Dr C G Oleshko

Appendix 4

~[Calling Name] ~[Surname] ~[Patient Number]

  1. Do you feel healthy?
/ Yes (0) / No (1)
  1. Have you lost a lot of weight recently without wishing to do so? (‘A lot’ is 12lbs or more during the last six months or 6.5lbs or more during the last month.)
/ No (0) / Yes (1)
Do you experience problems in your daily life due to:
  1. Difficulty in walking?
/ No (0) / Yes (1)
  1. Difficulty with maintaining your balance?
/ No (0) / Yes (1)
  1. Poor hearing?
/ No (0) / Yes (1)
  1. Poor vision?
/ No (0) / Yes (1)
  1. Lack of strength in your hands?
/ No (0) / Yes (1)
  1. Physical tiredness?
/ No (0) / Yes (1)
  1. Do you have problems with your memory?
/ No (0) / Yes (1) / Sometimes (0)
  1. Have you felt down during the last month?
/ No (0) / Yes (1) / Sometimes (1)
  1. Have you felt nervous or anxious during the last month?
/ No (0) / Yes (1) / Sometimes (1)
  1. Are you able to cope with problems well?
/ No (1) / Yes (0)
  1. Do you live alone?
/ No (0) / Yes (1)
  1. Do you sometimes wish you had more people around you?
/ No (0) / Yes (1) / Sometimes (1)
  1. Do you receive enough support from other people?
/ Yes (0) / No (1)

Please complete the name and contact number of your next of kin or carer who can be contacted in case of an emergency.

Name ...... Telephone Number ......

Appendix 5

Elderly Health - patient information

Consent for carers to talk to ********* doctors and nurses

For reasons of confidentiality we may only discuss a patient’s problems and treatment with the patient. We do, however, have a simple consent form, that if you wish to sign would allow us to speak to a nominated carer or next of kin regarding your medical and social care, e.g. giving them blood test results, discussing your health, discussing medication and giving the medicines. Forms are available at reception

General day-to-day living

If you are experiencing problems with day to day activities such as washing, dressing, taking medicines we can ask a social worker to visit you and carry out an assessment of your needs with a view to providing additional home care. Any care services that are provided do have to be paid for. You may contact the Practice based Social Worker, **********, via ******* Surgery reception without the need to see a doctor

If you are experiencing problems with your walking or have suffered falls then we can ask a physiotherapist to help you, and an occupational therapist to visit your home, e.g. to provide ramps to your front door or rails within the house. Referral to the local Falls Clinic service is available where appropriate. Hip protectors can be bought privately. Stair lifts also have to be purchased privately.

Anyone over 75 years old should consider taking a daily calcium and vitamin D supplement which is available on prescription. Where appropriate we may request a DEXA bone scan to be carried out to exclude osteoporosis. If osteoporosis is diagnosed additional treatment can be offered.

Mood and memory

As we get older we may become dependent on others and more restricted in our day-to-day abilities and it is quite easy to feel low. If this is an issue do talk to us. There are a variety of informal befriending and more formal counselling services available. Sometimes treatment with anti-depressants medicines is helpful.

Deteriorating memory can be another problem. There are simple assessment test that we can use and where appropriate we can refer you on to a specialist Memory Clinic at the hospital. Medication may sometimes be offered to attempt to slow down changes.

Other social support

Where appropriate Day Care and holiday relief admissions can be arranged. There are also activities and support groups available at the ********* Village Centre. Ask for detailed information.

Driving

We all regard access to our own car as essential but as we get older it is important that you are fit to drive because of safety for yourself and others on the road. If you drive when you are not considered to be fit to drive you may also invalidate your car insurance and make yourself liable for substantial financial costs. If you have any concerns regarding if you are fit to drive, then either contact one of the Doctors or the DVLA.

Appendix 5

Other health services

The district nurses are based at ******* Surgery and can be contacted on tel ********. They provide a community nursing service and can arrange for blood tests to be taken at home.

Physiotherapy referrals and occupational therapy referrals can be made by a GP.

For some specific problems, such as incontinence, we can refer you to one of the local incontinence advisors for further assessment and provision of pads where appropriate.

Chiropody services are available at the Surgery and under special circumstances by a visiting chiropodist. The need for treatment is, however, assessed independently of the Surgery and you must be considered to be in a high risk group to be eligible for treatment.

Key safes

Simple digital key safes are available from most large DIY stores and from specialist security services. They can be hard fixed to the outside of your house in a hidden area. Access to the box is by a four digit code. A spare front door key for your own use or for access by carers can be left inside. If you do fit one it is helpful for us to know the code at the Surgery in case we need to visit. Stoke Lifeline are able to fit a key safe box at a one off cost of ₤60.00. Contact them on 234545.

Care call alarms

These can be worn as a pendant or put on the wrist and are worth considering. A local contact is essential for the alarm company to contact if the alarm is activated.

There are two local providers for alarm systems – Aspire operate a Care Call System and the cost is ₤14.03 per month and Stoke Lifeline provides a similar service at a cost of ₤20.46 a month, they also offer a responder service between 7am and 9pm. Contact Aspire on 635200 and Stoke Lifeline on 237903. Stoke Lifeline may be able to offer the service free if patients qualify under a medical need. Contact Telecare on 08005610015.

Hearing problems

Initial referrals have to be made by a GP but if you already have an NHS hearing aid you can contact the Endon Audiology Clinic direct on 504109.

Eye checks

We recommend that you have your eyes and your vision checked at least annually by a qualified optician who can form a more comprehensive assessment than ourselves and can make appropriate recommendations regarding glasses. They will also screen for conditions such as cataracts and glaucoma and can either refer directly to the eye specialist or back to ourselves. If you are housebound and require a home visit for a general eye examination this can be arranged by contacting Heron House on 0800 389 8832.

Dental care

Again we recommend that you see a dentist on a regular basis.

Attendance Allowance

Forms are available by phoning the Department of Work and Pensions on 08457123456. The form will be sent out with a stamp addressed envelope. Someone can qualify if they need attention or supervision from another person.Attention means active help from another person. The help must take place in the

Appendix 5

physical presence of the disabled person. It can include hands on care such as help

getting in and out of the bath.

It doesn’t have to involve physical contact so long as it is some form of personal contact, eg prompting someone to carry out activities such as prompting someone to eat regularly will fulfil the criteria.

Supervision means keeping an eye on someone to assure that they don’t put themselves or others in substantial danger. It includes being ready to intervene if something goes wrong, eg if someone with dementia is prone to wandering off.

Further details regarding Attendance Allowance is available at

Disabled driver badge report (Blue Badge)

This is available for both as a driver and as a passenger if you have a permanent problem with walking and are no longer able to walk more than 50 metres without stopping using an aid. Forms are available from the Surgery or from Newcastle Borough Council.

Council Tax Exemption

Anyone with a severe mental impairment including dementia and living on their own and is receiving the appropriate Disability Benefit such as Attendance Allowance is exempt from paying Council Tax.

Contact Newcastle Borough Council directly on 01782 715500 and speak to one of the officers who will arrange an assessment. The doctors will be happy to sign the necessary paperwork.

Individuals or couples may also qualify for main Council Tax benefit if they have a low income and no more than ₤16,000 in savings.

Legal aspects

Make sure that you have an up-do-date Will. Wills can be quite tricky to draw up and we do recommend that you seek legal advice. Some patients would like to draw End of Life Advanced Care Plans to explain what their wishes are with regard to hospital provisions and treatments. Do talk to a doctor or nurse for further information if you do wish to do this.

Similarly you may wish to sign a Do Not Resuscitate Form which does not mean that medical treatment is withdrawn if you fall ill but it is a way of saying that you would not wish a team or Paramedics arrive in a blue light ambulance to defibrillate you and carry you off to Casualty if you collapsed.

If your memory is not as good as it was and you were experiencing difficulty managing your affairs, you may wish to draw up a legal Power of Attorney. This is a complex legal document and again we advise that you seek specialist legal help.