Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Comprehensive Geriatric Assessment

The health care of an older adult extends beyond the traditional medical management of illness. It requires evaluation of multiple issues including physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's health.

Comprehensive Geriatric Assessment (CGA) is a multidimensional  holistic assessment of an older person which considers health and wellbeing and formulates a plan to address issues which are of concern to the older person ( and their family and carers when relevant ), arranges interventions according to the plan and then reviews the impact.

 

While integrating standard medical diagnostic evaluation, CGA emphasizes quality of life and functional status, prognosis, and outcome that entails a workup of more depth and breadth.

Thus, the hallmarks of CGA are the employment of interdisciplinary teams (established or virtual) and the use of any number of standardized instruments to evaluate aspects of patient functioning, impairments, and social supports.

In the Secondary Care setting the Comprehensive Geriatric Assessment (CGA) is utilised for the systematic investigation of selected geriatric patients who present with specific conditions (e.g. fall, TIA, a.fib., incontinence, etc.) or specific suspicious symptoms ( e.g. frailty, memory loss, sarcopenia, decline in ADL etc.).

CGA is effective in reducing mortality for older people admitted to hospital. (Ellis G, 2011).

In community settings, the evidence shows that CGA in people with frailty can reduce hospital admission and can prolong independent living at home (Beswick AD, 2008).   

CGA based primary care is instrumental in reducing the incidence of hospital admissions from care homes (Molloy DW, 2000) .

Referral from the emergency unit or ward is directed to a Geriatrician or, where operative, a fit for purpose Multi-Disciplinary Team (MDT).

 

Key processes and structures which support implementation and maximise impact of CGA include :

  • Development of multi-disciplinary (MDT) teams

  • Regular MDT review meetings to share knowledge and develop team working 

  • Clear identification of a joint core level of competence in assessment between health and social care practitioners 

  • Clarity of when referral for specialist single professional assessment  is appropriate 

  • Single patient held documentation 

  • Information sharing systems 

  • Access to joint health and social care funding 

In the Primary Care setting, selected aspects of the CGA may also be utilised by the GP to evaluate conditions with a view to appropriate secondary care referral.

CGA based primary care is instrumental in reducing the incidence of hospital admissions from care homes (Molloy DW, 2000) .

 

However, the G.P. may also utilse the full CGA process as a framework for the ongoing systematic and focussed preventive care, monitoring, and management of both the community and residential care-home elderly.

 

Locally available resources dictate the extent to which the GP is able to rely on the support of consultant geriatricians and/or MDTs, or must shoulder alone more of the burden of care.

Particular complex case, or where diagnosis or treatment options are unclear to the GP, a Geriatrician working in a community setting could be involved in, or even lead CGA ( BGS, 2014).

Multi Disciplinary Team (MDT)

The range of health care professionals working in the MDT varies based on the services provided by individual comprehensive geriatric assessment (CGA) programs.

In many settings, the CGA process relies on a core team consisting of a physician, nurse, and social worker and, when appropriate, draws upon an extended team of physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians.

Although these professionals are usually on staff in the hospital setting and are also available in the community, access to and reimbursement for these services have limited the availability of CGA programs.

Increasingly, CGA programs are moving towards a "virtual team" concept in which members are included as needed, assessments are conducted at different locations on different days, and team communication is completed via telephone or electronically, often through the electronic health record.

This "virtual team" approach is the model employed by GP's who have adopted a CGA based proactive  model of care for their elderly patients. The GP is the architect and co-ordinator of the patient care, and when appropriate requests the input from the appropriate extended team members, and sees to it that a personalised care plan is devised and executed accordingly.

The CGA should undergird and inform the interaction between primary and secondary care professionals, providing a common language and evidence-based basis for the maintenance of the highest standards and quality of care.

 

CGA is integral part of a Proactive Care approach and is instrumental in generating an individual Problem List identifying issues in the following domains  (preferably to be compared with the previously known status)

  • medical,

  • functional

  • psychological

  • social

  • environmental

  • advance care planning

The individualised Problem List forms integral part of both the Brief CGA record keeping template and the Full CGA record keeping template. 

It will then accommodate the individual’s own personal goals before documenting interventions and overall management strategies, as well as who will deliver these i.e. a Personalised Care Plan. 

Depending on the problem(s) identified, the intervention may consist of one or more actions to be delivered by a clinician - doctor and/or other relevant members of the multidisciplinary team (e.g. nurse, physiotherapist, occupational therapist etc), who are included as necessary.

Undertaking a CGA takes time.  To complete the assessment fully may take up to two hours. Such an undertaking is impossible within the constraints of most current GPs practices.
The GP will need to schedule multiple consultations to complete the work required to cover those aspects of CGA that he/she wishes to undertake, review the results of those aspects of CGA that were performed by other professionals, and interact whith the MDT where and MDT is available.

For example, the sequence of short in-office GP consultations may look like this :

  • Initial screening test for Frailty (e.g. Gait Speed test), and initial discussion re Personalised Care Planning 

  • Formal frailty assessment (e.g. TUG test - may be conducted by nurse)

  • GP review of frailty assessment , and initial discussion re CGA

  • Formal Brief CGA assessment (may be initiated by nurse)

  • GP review and completion of brief CGA, and initial lab and imaging investigations

  • GP review and discussion re Full CGA, with referral to MDT (where available) or decisions re what portions of full CGA will be handled in-house and which portions will be referred

  • Nurse or GP led performance of selected portions of CGA

  • GP review of Personalised Care Plan (where generated by MDT) or GP formulation of a Personalised Care Plan

  • Nurse or GP led implementation of GP led aspects of Personalised Care Plan, and review of other Personalised Care Plan aspects led by other members of the MDT

  • Nurse or GP led monitoring and review of GP led aspects of Personalised Care Plan, and review of other Personalised Care Plan aspects led by other members of the MDT

 

Ideally mechanisms will have been put in place for aspects of the assessment to be either :

  • performed in-house by the GP himself

  • performed in-house by the nurse or other designated professional

  • outsourced (referred) to a number of health and social care professionals

  • outsourced (referred) to the voluntary care sector

  • completed by the informal carer.

 

The information would accumulate over time.

Developing a model of proactive care for those Older Adults living with Frailty would enable a multidisciplinary approach to comprehensive assessment for those most at risk of unplanned hospital admissions. 

The GP's electronic record keeping system (EMR) may need to be revised and/or upgraded to accomodate the easy retrieval and centralised availability of data necessary for the CGA itself and the subsequent interventions, monitoring and reviews

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