VOL: 98, ISSUE: 26, PAGE NO: 34
Kate Lloyd, MA, BA, CertEd, RGN, DipHV, is rural project worker, Duchess of Kent Hospital, Catterick, North Yorkshire;Kath Wise, RGN, RM, CertHV, CPT, Graduate Diploma of Clinical Practice, is health visitor and community practice tutor, Hambleton and Richmondshire Primary Care Trust;Elaine Wyllie, RGN, DipHV, is a health visitor, Hambleton and Richmondshire Primary Care Trust
The GP contract specifies that patients aged 75 or over should have an annual assessment of the factors that affect health, including their physical and mental condition, sensory functions, mobility, use of medicines, and social environment. The National Service Framework for Older People (Department of Health, 2001) also highlights the need for a single assessment, particularly regarding the prevention of falls. The document states: ‘Proper assessment of the range and complexity of older people’s needs and prompt provision of care can improve their ability to function independently.’
With this in mind, a group of health visitors working in three general practices in Hambleton and Richmondshire, North Yorkshire, developed a holistic assessment tool to address the needs of the over-75 client group. The tool was designed to reveal any immediate health concerns, but also provides:
- An opportunity to make contact with a potentially vulnerable population;
- A baseline assessment of health and functional ability;
- An opportunity to initiate referrals to other agencies;
- A measurement of the impact of disease and the ageing process on functional ability (Iliffe et al, 1994);
- A means to deliver broad-based messages on health promotion, in line with the recommendations of The National Service Framework for Older People (NSF).
Where should the patient be seen?
The review should ideally be carried out in the patient’s home. However, this may not be practical or necessary, particularly if the patient is fit and active. Patients are offered the option of a home visit if they are unable to attend surgery, and if concerns arise during assessments at the surgery follow-up visits can be made to their homes.
Who performs the assessment?
Assessments are carried out by a district nurse, a practice nurse or a health visitor, depending on the GP practice. One practice has appointed a staff nurse specifically to do the job. However, the assessment format should ensure uniformity, irrespective of who does the health check.
The assessment (see box) covers the areas suggested in the NSF, including factors that may lead to falls and the provision of information on health promotion.
The assessment has been in use in the three practices for six months and information is being disseminated to other local practices. The number of people taking up the offer of a health review varied across the practices. The wording of the letter of invitation was important and the NSF suggests a proactive approach. In the three practices involved, people responded positively to letters suggesting that the review was an important part of their health care and that the practice was committed to performing the review.
Where reviews have been established they provide a personal point of contact, also recommended in the NSF, which would enable an approach at a later date if an issue arose. Those who attended appreciated the opportunity to discuss issues they saw as peripheral and ‘not worth’ discussing with the doctor.
Some practices made home visits to all those who failed to attend without giving a reason. It is important to identify those who may be at risk and possibly too confused to respond. This review is seen as a team effort and reception staff are often aware of whether a patient needs a home visit or why they might have failed to attend.
Take-up in one practice, where no reviews had been carried out for some time, was more than 90% over three months. Of the eight patients who refused or failed to attend, three saw the GP regularly. In all, 44 referrals and follow-up contacts were made as a result of the assessments (often more than one for the same person). One patient was diagnosed with diabetes and another is undergoing further investigations for prostate cancer. Several were found to have urinary tract infections. Referrals were made, among others, to social services, the chiropodist, the GP, the practice hypertension clinic, the physiotherapist, the optician, and the fire service for a fire-safety assessment.
Health promotion was discussed and the topics included diet, exercise, fluid intake, sleep disturbance and compliance with medication. Participants commented on the benefits of preventive work, on feeling ‘looked after’ and having time to discuss things. Some had not been aware of services such as the domiciliary optician, the fire service check or the need for regular dental checks.
Implications for practice
Staff discussions on the use of the assessment resulted in requests for further training on how to make the medication review more effective. A training session has been arranged. Another area of concern raised by staff who have conducted reviews is appropriate exercise for housebound patients to improve their circulation and reduce muscle wastage. This is being tackled and, in view of the fact that regular weight-bearing exercise also reduces the risk of osteoporosis by 50% (Department of Health, 2001) and physical activity has social, physical and mental health benefits, we hope to organise regular exercise classes that would be open to all in the community aged 75 or over.
The review identifies signs of hypertension, diabetes, prostate and other forms of cancer before the patient is aware of any symptoms. For some older patients, early referral could optimise the outcome of further treatment and care. For others, the review provides a baseline for assessment in future years.
The health check enables primary care teams to identify changing needs and provide a point of contact if help is needed. Many older people enjoy the opportunity to discuss their health needs, and the over-75 review is an ideal opportunity for health promotion and the discussion of holistic needs with members of this vulnerable group.
Screening older people aims to ‘preserve functional ability and to allow patients to live in good effective health in the environment of their choice for as long as is practical or possible’ (Williams and Wallace, 1993). Our assessment tool addresses these needs.