Introduction

Domiciliary care is key in enabling access to dental care for some of our most vulnerable population who may require a clinician to attend their place of residence; for example, their own home, a nursing home, or a hospital setting.

Some factors that can contribute to the need for domiciliary care include, but are not limited to: mobility issues; severe physical health problems and mental health conditions; and deeming the patient confined to their bed or home.

The UK life expectancy has been increasing and this is anticipated to continue. On average, life expectancy is 87.6 years for a man and 90.2 years for a woman if born in 2018.1 Projected figures deduce that in the year 2035, the number of people aged 65 or over residing in a care home in England will total 558,540.2 From these statistics, an increased demand on the domiciliary dental service can be presumed.

In the 2018/2019 reporting year, over 25 million patients in England and Wales had received at least one course of treatment (COT), equating to 43.1% of the total population (mid-2018). Of which, just under 51,000 patients had domiciliary care. From the FP17 forms received with domiciliary services provided, 7.3% were for those aged 0-39, in comparison to 76.7% which were for patients in the 70-99 age category.3

In England and Wales, the number of patients who had a domiciliary COT completed between April and October 2020 was 3,529. For this cohort, 44.9% of the domiciliary claims were for band one care, 16.9% for band two and 11.3% for band three.3

Increased domiciliary demand

The cohort of patients who utilise domiciliary services to minimise the barrier to accessing dental care is wide-ranging. This population includes both paediatric and adult patients who may have a physical disability and an underlying comorbidity, such as reduced mobility or a severe medical complexity. Access is not always impeded by a physical or medical complexity; mental health can also impact an ability to access the dental surgery and justify a domiciliary assessment, such as dementia, erratic or challenging behaviour, anxiety and agoraphobia.

It is imperative to limit inequalities that patients accessing our services may experience and reduce the risk of patients contracting coronavirus (COVID-19) from the dental setting and its professionals. Of particular concern are patients who are classed as 'clinically extremely vulnerable', such as those with cancer or those who have received a solid organ transplant,4 as this group may avoid the dental surgery, whereas before the pandemic they would have attended.5 The authors found no evidence suggesting it is safer for a vulnerable patient to receive domiciliary dental care, although we believe they may benefit from domiciliary care to reduce their contact with members of the public and communal spaces.

The government's COVID-19 guidelines advocate that these individuals minimise the time spent in places where they cannot socially distance. This scenario could be encountered on the journey to the dental surgery, such as using a taxi or on public transport.4 It is advised not to travel during peak times;4 however, this may not allow for the patient to arrive for the first appointment of the day, when fewer people would have been in the surgery and no aerosol generating procedure would have been performed.

Owing to the pandemic, in addition to those who would have already received domiciliary care due to experiencing barriers to accessing the dental surgery, the domiciliary dental service may subsequently experience an increased demand and such services will need to adapt provision.5

Remote information gathering

After receiving a new patient referral, when a recall examination is due or an urgent assessment is required, information can be remotely gathered before the visit and in turn be utilised to complete a risk assessment of the proposed domiciliary visit.

The information can highlight important factors about the patient's environment, any communication or capacity concerns and potential for challenging behaviour. This benefits the dental professional and patient by allowing appropriate and prior appointment planning and risk management to be carried out.

Domiciliary Patient Information Sheet

Since the COVID-19 pandemic, information gathering before an appointment is a more accepted process for patients, carers and professionals. The authors' Trust has successfully implemented the use of two tools:

  • 'Domiciliary Patient Information Sheet (DPIS)' (Appendix 1)

  • 'Domiciliary Risk Assessment (DRA)' (Appendix 2).

The DPIS is a three-page document with six sections; it is user-friendly and can be utilised by the whole dental team. It can be completed by staff such as a dental receptionist, nurse, therapist6 or dentist by extracting information from the referral, available clinical records and/or photographs, in addition to contacting the patient or carer via telephone or virtual video consultation before deciding to arrange a domiciliary visit.

The DPIS is divided into the following six sections (Appendix 1):

  1. 1.

    General information

  2. 2.

    Environmental (external and internal) information

  3. 3.

    Patient consent and communication-specific information

  4. 4.

    Patient behaviour and compliance information

  5. 5.

    Coronavirus-related questions

  6. 6.

    Payment

Domiciliary Risk Assessment tool

Useful information can be gathered by completing the DPIS by remote information gathering. The dentist should review the information to complete the DRA. The DRA is a one-page document (Appendix 2), which consists of eight factors:

  1. 1.

    Environmental

  2. 2.

    Medical

  3. 3.

    Consent and communication

  4. 4.

    Behaviour and compliance

  5. 5.

    Treatment requirements (provisional treatment before visual examination)

  6. 6.

    Urgency of case

  7. 7.

    Coronavirus transmission risk to staff

  8. 8.

    Overall risk of harm to team.

Each should be red, amber and green (RAG) rated according to the perceived associated risk and necessary adjustments detailed to mitigate risk.

The authors recognise that some risks could be missed, overlooked or may not become obvious until you are at the patient's residence and therefore the risk assessment process must be flexible and revisited continuously.

It allows the team to be informed with potential risks and therefore enables planning to minimise these. An example of a risk could be bleeding following an extraction in a patient taking an oral antiplatelet, such as clopidogrel; this risk may be mitigated by facilitating transfer to a clinical environment for treatment and implementing local measures.

A risk-benefit analysis may identify that a domiciliary face-to-face appointment should be postponed, for example with a clinically extremely vulnerable patient (that is, a liver transplant recipient)4 that has a low periodontal and oral cancer risk. The visit need and risk should be reassessed following a complaint of symptoms (that is, reversible pulpitis) and if government guidance changes on the requirement to shield, even after having two doses of the COVID-19 vaccine.4

Domiciliary Patient Information Sheet and Domiciliary Risk Assessment tool development

A medical risk assessment tool was created by the West Midlands Domiciliary Special Interest Group, which focused on patient, treatment and environmental factors.7 It has been modified and developed by the Herefordshire and Worcestershire Health and Care Trust Community Dental Service to create the DPIS and DRA forms, following local staff suggestions.

A literature review found that in 2020, a four-page domiciliary risk assessment form was published following the work of a national expert panel (including dentists with varying years of domiciliary experience) with the use of a modified e-Delphi study.6

Similarly, the form comprises of sections to complete about the patient identifiers, next of kin details and risks such as parking and environmental factors. The form also acts as a reminder to consider how to minimise identified risk.6 Likewise, the form also utilises a RAG rating; comparatively, it gives more details about the individual risk categories and examples of potential risks, such as the property having extremes of temperatures or there being difficult access to the property.

The paper importantly highlighted that the study was performed before the COVID-19 pandemic and made recommendations such as accepting that patient self-isolation periods may affect appointment bookings.6

In comparison, the DPIS does include questions related to COVID-19 transmission risk (Appendix 1) such as, does the patient have a new persistent cough? Has a household member tested positive for COVID-19? The DRA includes a section to apply a RAG rating to the 'COVID-19 transmission risk to staff' with a section to comment on 'risk mitigation' (Appendix 2).

Discussion

During the COVID-19 pandemic, the DPIS and DRA have been essential in collecting information and aiding mitigating risk on a domiciliary visit. To demonstrate examples of risks that are faced and to minimise these, the authors would like to share some case scenarios to aid the implementation of the forms among the profession (Tables 1, 2 and 3). The authors recognise the RAG rating for each risk/urgency rating can be subjective and views on risk mitigation may differ.

Table 1 Case 1 summary - patient receiving domiciliary prosthodontic work by a general dental practitioner; 90-year-old woman who is edentulous has lost her complete-complete (C/C) dentures during a recent hospital admission following a fall at home. She would like a new set of dentures constructed. She has age-related macular degeneration and takes aspirin and atorvastatin
Full size table
Table 2 Case 2 summary - patient receiving domiciliary examination but treatment in dental surgery; 89-year-old man who has a painful mobile lower left incisor (31) requiring extraction. He has a history of a stroke which affects his movement. Takes clopidogrel and is a wheelchair user
Full size table
Table 3 Case 3 summary - patient receiving specialist input; 54-year-old woman with bleeding gingiva. She had a traumatic brain injury and subsequently has dysphagia and is fed via percutaneous endoscopic gastrostomy. She lives with her supportive husband in a rural location
Full size table

Internal review

An internal review of the DRA/DPIS documents was undertaken, which enabled an evaluation of the service provider's responses (dentists, dental nurses and a receptionist) to questions about them.

When asked if they thought the DRA/DPIS has or would improve patient and/or staff safety on a domiciliary visit, results highlighted that before the implementation of the DRA and DPIS, staff only had access to a referral form before a new patient visit; however, they found it beneficial to highlight potential environmental risk factors before the visit, such as the presence of pets, aggressive residents, or challenging behaviour.

Staff commented that areas that had worked well were being able to obtain detailed information before their visit, which allowed for consultant advice to be sought if required. The review emphasised areas that service providers thought had not worked well, such as the time necessary to undertake the information gathering and therefore the need to allocate time to staff to allow prompt completion of the documents.

Review responses drew on what was liked about the DRA/DPIS; replies included the fact that all the information can be found in one place and that they prompt to ask about risk factors, allowing for prior planning.

Overall, the internal review demonstrated the DRA and DPIS have been a positive introduction into the domiciliary care pathway.

Conclusion

Collecting information before a domiciliary visit and completing a risk assessment tool can minimise the risks to patients and professionals by being pre-informed and prepared for the visit. The case studies demonstrate the risks that could be experienced by professionals and how the DRA can act as a reminder to think about the methods to reduce those risks. The authors hope that the two documents can be utilised and will benefit other dental professionals and their patients.