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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.1 Access to care

Our practice provides timely care and advice.

Criterion 1.1.3

Home and other visits

Regular patients of our practice are able to obtain visits in their home, residential aged care facility, residential care facility or hospital, both within and outside normal opening hours where such visits are deemed safe and reasonable.

Indicators

► A. There is evidence that patients of our practice access home and other visits both within and outside normal opening hours.

► B. Our practice team can demonstrate our practice’s policy on home and other visits, both within and outside normal opening hours, and the situations in which a visit is deemed appropriate.

► C. Our practice has a written policy on home and other visits, both within and outside normal opening hours.

Explanation

Key points

  • In general, home and other visits need to be available to regular patients of the practice where clinically appropriate
  • Practices need a home and other visits policy specifying:
    • factors that are deemed to make home or other visits safe and reasonable
    • geographic area for home and other visits
    • types of problems that necessitate a home visit
    • an alternative to a home visit if a home or other visit is not available

Defining ‘safe and reasonable’ in the local context

Home and other visits such as visits to residential aged care facilities, residential care facilities or hospitals need to be available to regular patients of the practice where such visits are safe and reasonable and are clinically necessary. Visits may be performed by, or on behalf of, the practice.

There needs to be a direct continuing relationship between the practice GP(s) and those doctors who perform the home and other visits on their behalf, including services that provide care outside normal opening hours. This includes arrangements to exchange clinical details about patient care and any concerns the practice may have about the safety of a visiting GP.

General practitioners and other members of the practice team need to be able to describe the conditions under which a home or other visit is deemed appropriate. Examples include deciding upon a reasonable distance within which visits are provided and the types of problems that necessitate such visits. What is ‘safe and reasonable’ has not been defined here, as it is a decision that each practice needs to make in their local context (eg. with regard to location, patient population). What is safe and reasonable should be considered by the practice in light of what peers (or practices in the same area) would agree was safe and reasonable.

Information that may assist in determining what is safe and reasonable is available from the Australian Medical Association (AMA) Position Statement, Personal Safety and Privacy for Doctors’ (available at http://ama.com.au/node/2182) and the RACGP publications Keeping the doctor alive: A self care guidebook for medical practitioners and General practice – a safe place.

Documentary evidence that the practice provides care outside the practice may include medical records, appointment schedules and Medicare data. Such documentary evidence may be stored at the practice or at an external facility (eg. residential aged care facility progress notes).

Access to alternative sources of care

The RACGP does accept that there will be individual circumstances where home or other visits will be neither safe nor reasonable. In these circumstances the practice should be able to clearly document the alternative system of care that these patients can access. There should be documentary evidence that this system provides care for the practice’s patients who require such services and ought to take into account the approach of similar practices in the area. The RACGP understands that in future other models of care outside normal opening hours may be developed (eg. GP telephone advice line).

Patients with special needs

Practices need to consider how to provide continuity of care to patients who can no longer attend the practice due to disability. Patients value an ongoing relationship with their GP, even when their needs change.

Who can perform home or other visits

Home and other visits need to be performed by recognised GPs (either Fellows of the RACGP or vocationally recognised). In some areas it may not be possible to recruit recognised GPs. In such circumstances, doctors who provide home visits, and who are not recognised GPs, need to be appropriately trained and qualified to meet the needs of the practice community. Doctors who are not recognised GPs need to have been assessed for entry to general practice and be supervised, mentored and supported in their education to the national standards of the RACGP (see Criterion 3.2.1 Qualifications of general practitioners).

In some situations, other health professionals, such as nurses or Aboriginal health workers, do home visits under the supervision of a suitably qualified doctor. Alternatively, health professionals sometimes transport a patient back to the practice for a consultation.

Safety of health professionals

The following guidelines may enhance the safety of health professionals undertaking home and other visits on behalf of the practice:

  • Patients must have a telephone number which the general practice can call back
  • A health professional is not sent to a patient/caller requesting pain relief unless a pain management plan is in place
  • Police are requested to attend where a patient is threatening suicide
  • A health professional is not sent to premises where there is evidence of a threatening or abusive person present – police are requested to attend in these instances
  • Callers are asked to restrain dogs, to turn on an outside light at night and provide guidance on identifying the residence in the absence of a house number (eg. nearest intersection)
  • Patients are asked to provide their date of birth, and the name of their regular GP/general practice. Where these details or a contact telephone number are not provided, consideration is given to referring the patient to hospital or calling an ambulance (as appropriate).

(Adapted from the National Association for Medical Deputising Services)

Services providing care outside normal opening hours

Medical deputising services (MDS) must provide home visits. This criterion and indicators are not applicable for services providing care outside normal opening hours that only provide consultations within a clinic (ie. make no home and/or other visits).

Standard 1.1 Access to care

Our practice provides timely care and advice.

Criterion 1.1.3

Home and other visits

Regular patients of our practice are able to obtain visits in their home, residential aged care facility, residential care facility or hospital, both within and outside normal opening hours where such visits are deemed safe and reasonable.

In a nutshell

Your health service ensures that its patients can receive home and other visits, both during and outside normal opening hours. It has a written policy describing the circumstances in which home visits could take place. When creating a home-visit policy, your health service must consider the patients’ and the community’s need for home visits as well as the safety of clinical staff who provide home visits, and try to strike a balance between the two.

Key team members

  • Practice manager
  • Clinical staff
  • Reception staff
  • Driver
  • Community liaison officer

Key organisational functions

  • Home and other visits policy
  • Clinical staff safety policy
  • Documenting patient health records
  • Clinical staff personal safety and care
  • Provision of continuity of care to patients and
the community

Indicators and what they mean

Table 1.3 explains each of the indicators for this criterion. Refer to Criterion 1.1.3 Home and other visits of the Standards for general practices for explanations of some of the concepts referred to in this criterion. 

Table 1.3 Criterion 1.1.3 Home and other visits
IndicatorsWhat this means and handy hints
▶ A. There is evidence that patients of our practice access home and other visits both within and outside normal opening hours. It is a regular part of your health service to provide home and other visits to patients within and outside normal hours. This may be because home visits have been common practice, are due to community expectations or are part of an existing policy regarding access to care. For example, many Aboriginal medical services have a policy about providing out-of-hours care because they want to ensure that patients of Aboriginal and Torres Strait Islander origin have access to a health service.
▶ B. Our practice team can demonstrate our practice’s policy on home and other visits, both within and outside normal opening hours, and the situations in which a visit is deemed appropriate. Your clinical staff understand and follow your health service’s policy on home and other visits. When the policy is updated, clinical staff are given the appropriate training and information about the updated policy. This also means that the clinical staff can easily explain and describe the situations where a home and other visit could be made and when it would not be considered safe and reasonable.
▶ C. Our practice has a written policy on home and other visits, both within and outside normal opening hours. Your health service’s written policy on home or other visits contains clear guidelines about:
  • the situations and times in which a home or other visit could be made. Generally, this would include the types of medical situations involved and when it is safe and reasonable to do so (see the case study on page 20 for examples of what might not be safe and reasonable)
  • its definition of safe and reasonable. This may depend on issues such as availability of other medical services in your community, the types of medical problems that would require a visit or what would be considered a reasonable distance for staff to travel for a home visit. The definition should consider the situation with regards to the medical needs of patients, and the safety of clinical staff doing the visit (see page 16 of the Standards for guidelines on the safety of health professionals when conducting home visits)
  • the geographic area that your health service will cover for home and other visits
  • the situations and places in which home visits are deemed not safe or reasonable, and in such situations whether there is alternative medical care for patients, how far that is and how patients could get to the alternative medical care
  • the staff who could do the home or other visit. For example, it should be done by a vocationally recognised and qualified GP; if the GPs are not recognised, they have been assessed for entry to general practice and have the appropriate supervision, mentoring and support in their education. Where nurses or Aboriginal health workers do home visits by themselves, the policy could state the situations under which they may do so. This might be when they are supervised by a qualified GP, either on site or by phone, or remotely using the DMO service by telephone or video conferencing when required.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure it provides appropriate home and other visits for its patients and community. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service’s health team provides outreach/outstation health clinics to communities in several locations each month. These outreach clinics are set in a regular routine so the community members know when the clinics are due. The outreach clinic dates (for example, every second Thursday) are included in the health service information sheet and on posters in the waiting area.

The staff members are aware that, in line with the health service’s staff wellbeing policy, home visits are done up to a radius of 50km and two staff members conduct visits together. Staff members are required to fill in a log sheet of the patient’s name and location and the expected time of return from the home visit. Staff members have either a mobile phone or two-way radio for emergency communication back to the service.

If there is only one clinician in the community at the time, they take a satellite phone with calls to the service diverted to it. If no clinician is available at the time, the district medical officer, community liaison officer or driver is contacted.

Home and other visits are assessed for the possibility of violence, and if this is likely the police will be asked to accompany staff members making the visit. Police are requested to attend where a patient is threatening suicide or if there is evidence of a threatening or abusive person present.

The occupational health and safety policy and procedures provide guidance for staff about what to do or who to call if they feel unsafe. This might include asking the patient to meet at the health service, or to have a female family member present if the patient is male and the clinician is female.

The health service policy on home visits and staff safety contains at a minimum that patients are asked to restrain dogs and turn on outside lights at night.

Staff members document home visits in patient health records, including date, time, reason for visit and treatment provided. Medicare item numbers for home visits are utilised when they apply.

Showing how you meet Criterion 1.1.3

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Provide staff interviews, showing that the written policy and procedures match the actual process used by the health service staff.
  • Keep in-service logs on policy and procedures.
  • Provide staff inductions and ongoing training processes and records.
  • Keep health records showing entries of when staff members have provided home visits and the time they occurred.
  • Keep Medicare billings.
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