St Werburgh’s is a small dedicated General Practice for people experiencing homelessness in Chester.
The team comprises myself, a Specialist Nurse Practitioner full time, a GP 2 ½ days a week, a Mental Health Nurse Practitioner 2 days a week, a counsellor 2 days a week and 3 admin staff.
We all faced uncertainty and trepidation when Covid-19 arrived in the UK in March 2020, but wanted to ensure we stepped up to provide the care needed to keep our patients safe. As the pandemic was fast approaching, on March 3rd we emailed the Local Authority, Police, Public Health and voluntary sector partners to set up a local task force C0VID 19 forum as suggested by Homeless Link. We had our first meeting on March 12th. The Local Authority agreed to lead the meetings, and we continue to have fortnightly meetings even now.
Shielding
Initially data that we received suggested we had 112 patients that required shielding. We were immediately concerned that many of these wouldn’t receive their shielding letters, as they were street homeless, or had moved since their address was last updated on our EMIS system. We were also concerned that they might not understand the information or understand it.
However, we also decided that more of our patients were at risk than just 112. In fact, we made a clinical decision that due to multiple morbidity, compromised immune systems and substance misuse, we felt our whole practice population of 385 was ‘at risk’.
As such we set about contacting all our practice population individually as they were gradually taken in under the ‘Everyone In’ programme. If we couldn’t contact them directly, we contacted their housing key worker, or drug service or left a letter at the pharmacy where they picked up methadone. Once contacted, a clinician had a 1:1 telephone call with each of them, to fully explain CV19, and their individual risks, and how to self-isolate. We also registered all shielded patients on the Sam App to get support. After these calls, we also referred people to local organisations and help groups for food and support as needed.
We compiled a ‘high risk’ list of patients, and with consent obtained, we had many calls with housing teams and the Westminster Drug Project (our local addictions service) about these clients to ensure they were able to self-isolate. We then set up a fortnightly virtual meeting with the addictions service to discuss the patients on the shielding list, and also those that were vulnerable with complex needs. Clients were rated red, amber and green, and we worked to enable treatment to continue.
Access to health and social care
It was a really big moment for us was when we shut our front door. We went from having a bustling and busy waiting room with many drop-ins throughout the day, to total telephone triage and remote consultation. We were concerned as to how we could remain accessible to our patients. Very few of our patients have smart phones, and many have no phones at all. Communication can be difficult for patients with mental health concerns, and the phone can add further complications to it.
We have an intercom outside, and for those that were still dropping in, we were able to talk to them via intercom, and then bring them into the lobby to continue if this was felt to be needed. We asked local children to colour in posters to make the surgery more welcoming for these times.
However, we also went through our list to decide who needed ‘keeping in touch’ wellbeing calls for their mental health, with an initial view to ensuring that we spoke to them at least once a week. In fact, for some patients it was 3 or 4 times a week. We worked with hostels and through hotel reception to speak to patients who did not have access to a phone. Our mental health practitioner, then also provided crisis intervention support over the phone to patients and support staff.
To further maintain access the GP, Mental Health Practitioner and myself visited the hotels and pre-existing hostels on a weekly basis to provide support to patients and staff. We also offered PPE training to hotel, hostel and outreach staff. We also registered 47 new patients to take our patient population to 444.
Our admin team stood in pharmacy queues to drop off and pick prescriptions, and picked up Hepatitis C medication from the hospital pharmacy, and delivered it to patients’ accommodation when this was needed. We also took patients to hospital appointments as Taxis when this was essential, and dropped off care packages for patient in hospital when no visitors were allowed.
Finally, we worked with support services to provide wrap around care to patients housed in hotels due to domestic violence, and through the combined CCG and Local Authority CV19 response group we developed a potential pathway for Care Act Assessments. Although we never needed to use this it was a great relief to know that the care and support was available if needed.
Infection control and Covid-19 management
Right at the start we trained all the staff regarding PPE, and the logistics of moving patients safely through the surgery. We were lucky, and did not have any challenges accessing PPE.
In our PCN a Hot Hub was developed at our local hospital. This was 1.5 miles from our surgery, and 2 miles from most of the ‘Everyone In’ hotels. With no transport and a concern that taxis would not take patients anyway, we decided to create a Hot Hub at our practice. We also felt that it would be difficult for other clinicians to assess clients with concurrent substance misuse / withdrawal issues. In order to create a Hot Hub room, we laid new lino in one of our non-clinical rooms, and moved all furniture, filing cabinets, and bookshelves out. We then wrote a Standard Operating Procedure to support the use of the room, and this worked well.
We also took screening swabs with our local infection prevention and control team at a hotel where a patient had been accommodated from prison who was CV19 positive.
Medication
We used lockdown to fully review all patients prescribed medication. We used to ask to see patients face to face weekly, but full reviews tended to be reactive, and we are now trying to adopt a more proactive structured approach to reviews. Conversely speaking to patients over the phone, rather than insisting they come in, has seemed allowed for a more relaxed and open conversation with the patient. In some cases, we have been able to issue scripts weekly for longer periods of 2-4 weeks. This appears to reduce patient’s anxiety, which has sometimes led in the past to patients attending in a hostile manner.
What we will continue
We have increased our outreach services during this time, and have learned how effective this can be, and will endeavour to continue with this.
Conversely, we have also learned that telephone triage works well to reduce the footfall in the surgery, and keep the waiting room manageable, and reduces the number of DNAs. The nature of our patient population means that we will always try remain open for drop-ins, but this system of triage does appear to free up some time to work in different ways.
We will continue with telephone reviews of medication when feasible, as this has been effective, and will also be keeping our well-being calls to our vulnerable patients.
We will continue to meet in a structured and strategic virtual way with the local council, housing and the police. This has proved very effective in providing an instant response to this changing situation, and has improved our partnership overall. We will also keep professional meetings with the addictions service to discuss joint clients with complex and multiple needs.
Conclusion
This crisis has enabled us to look thoroughly at all our systems and practices and enabled us to make decisions regarding the best ways to meet our patient’s needs, and also the most effective use of time and resources. It has also enabled us to develop new partnerships and pathways for our patients. Although this time has been very challenging for everyone, and I am extremely proud of our practice staff for approaching the situation in such a positive, and proactive way, and enabled gains for everyone.
For more information please contact:
Pauline Finlay, RGN, BSc, Queen’s Nurse
Specialist Nurse Practitioner for the Homeless
https://www.nhs.uk/services/gp-surgery/st-werburghs-medical-practice-for-the-homeless/N81655
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