Domiciliary care post-lockdown

The scenario

Julie, practice owner

“I am a practice owner with a number of patients who are older and vulnerable. A lot of them are choosing to continue shielding after government guidance changed on 1 August. I want to hear about the precautions that I should take when providing domiciliary care to these patients, and what particular behaviours I should instruct my staff to follow. Can you help?”

The advice

Gordon Ilett, AOP board member and co-chair of the Optical Confederation Domiciliary Eyecare Committee

Individuals, particularly older adults, who are unable to leave home unaided owing to physical or mental illness or disability, or who are still shielding from COVID-19, are potentially at higher risk of eye disease and vision problems than the general population. Vision and eye health problems in turn exacerbate the effects of isolation and impact on other serious conditions, such as cognitive impairment and dementia.

Advice on shielding in England has changed in recent weeks, and may change again in response to local risk levels. The provision of eye care will need to be responsive to these changes, based on local public health advice and clinical judgement about risk and benefits.

Risk and need

The group that was advised to shield throughout the COVID-19 lockdown included the 2.5 million people who were classified as “clinically extremely vulnerable.”

We know that the virus will be around for some time, and possibly for the whole lifetime of some vulnerable patients

By age and other health factors, these individuals are most at risk of eye disease, visual problems and sight loss, which are in turn correlated with falls, loneliness, isolation and loss of cognitive function. All of these factors are exacerbated by loss of social contact with family, friends and carers.

We know that the virus will be around for some time and possibly for the whole lifetime of some vulnerable patients. This means that the balance of risk has now shifted towards meeting each individual’s eye care needs based on the principles of informed consent and respecting protected characteristics of each patient. The goal now is to preserve sight and independence and ensure no-one is denied the care they need when this can be provided safely.

Basic principles

Eye care for vulnerable patients should always be clinically necessary, and consistent with the Equality Act 2010. This means no practitioner should make decisions on who can access care based solely on disability, age, or another protected characteristic.

In managing the patient, you should respond to needs identified by them, a carer, another clinician or social worker. Care provided should continue to observe social distancing guidelines where possible, and should consist only of clinically necessary tests to minimise examination time.

You should clearly record and date all the information shared during the appointment, and share with care coordinators, GPs and other authorised persons and caregivers if required.

A risk assessment for each individual patient, and any other people who may be at risk of infection, should be completed. Up-to-date advice from the College of Optometrists and ABDO should be followed, especially in respect of rigorous infection control and the wearing and disposal of personal protective equipment (PPE). The appointment should be planned with the patient or their care co-ordinator at the safest possible time for them. If needed, it should be based on liaison with the local ophthalmology department so that care can be completed in a single visit.

Preparing your staff

As a practice owner, you should ensure that any staff being sent out to perform domiciliary eye care in the community are fully able to comply with the above. You should also ensure that staff check and comply with self-isolation advice on a daily basis, before leaving work and before visiting any patient.

Make sure all staff have equipment for rigorous infection control and use of PPE (and have been trained in its use), have clean uniforms daily, have bare forearms, and are aware that they need to disinfect equipment and other electronic devices at each use.

You may find it helpful to provide additional training for all staff so that they know how to perform a risk assessment at each location they visit, for example how to enter and exit the location with minimal contact with fixtures or other people. You should also check that they feel comfortable discontinuing a visit if they have concerns about a patient’s health, or their own. They should also know where to go to seek appropriate advice if needed.

Staff members should be limited to one per vehicle, and only one should attend a domiciliary visit. You should collaborate with individuals and care homes to minimise the number of visits needed.