ObjectivesTo explore the views and experiences of patients on the care they have received while enrolled on the Northumberland High Risk Patient Programme (NHRPP). This programme involved case finding of frail patients using a multidisciplinary team (MDT)-led community case management programme, and support of patients through care planning and regular reviews using primary, community, secondary and social care professionals.DesignA qualitative study using semistructured interviews, which were digitally recorded, transcribed and subject to thematic analysis.SettingCommunity patients receiving primary care in the county of Northumberland, England.Participants23 participants took part, of which 16 were patients enrolled on the NHRPP, and 7 carers. GP practices were selected purposively by size, deprivation and location, and patients identified and invited by General Practitioners to participate.Results4 main themes emerged from the data: awareness and understanding of the NHRPP, confidence in the primary healthcare team, limitations of home care and the active role of being a patient. Despite having a low level of awareness of the details of the NHRPP, participants did think that its broad aim made sense. Participants discussed their high level of satisfaction with their care and access to team members. However, some limitations of alternatives to hospital care were identified, including the need to consider psychological as well as medical needs, the importance of overnight care and the needs of those without informal carers. Finally, participants discussed the active nature of being a patient under the NHRPP if they were to contribute fully to planning and managing their own care.ConclusionsThis study has identified that a programme of MDT-led case management was generally very well received by patients and their families. However, a number of factors were identified that could improve the implementation of the programme and further research needs to be undertaken to address these.
Home visits remain an important and integral part of general practice. Many home visits are on an unscheduled acute basis, but for permanently housebound patients home visits are often the only way of seeing a GP. Housebound patients have higher rates of co-morbidity, functional impairment and mortality than their non-housebound counterparts. As the elderly population and potentially the number that are housebound continues to rise; the value and importance of home visits to enable continuity of care to this frail subset of patients is also likely to grow. Home visits can undoubtedly be difficult but they offer many advantages that can easily be overlooked, including gaining valuable insight into the home life of the patient. This article aims to improve awareness of the needs of the housebound as well as highlighting the advantages of home visiting in general. It gives useful advice on how to get the most out of a home visit.
GPs play an important role in caring for patients at the end of their life. To facilitate patient autonomy, care providers are encouraged to give patients the opportunity to discuss their priorities and preferences for future care in anticipation of a loss of capacity. This process is called advance care planning. This is an area of increasing interest and importance, made even more pertinent by the enactment of the Mental Capacity Act 2005 ; however, it can be confusing and daunting to health professionals. This article aims to summarise the key aspects of advance care planning.
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