Implementation - CGA Toolkit Plus

Resources for the Comprehensive Geriatric Assessment based

Proactive and Personalised Primary Care of the Elderly

Making it Happen

Early Stage of Implementation

Making It Happen

The following sample case studies illustrate the journey of implementation of a more CGA based, proactive, personalised care of the elderly in a GP practice.

The 3 case studies are composites of real GP practice experiences and illustrate the :

Early stage

1. EARLY STAGE OF IMPLEMENTATION

Trigger Event

Work-up

Follow-up
Monitoring

Spinoff
Summary
Required setup

Path to Resources

TRIGGER EVENT

(GP)

Mary O'Connell, a 72 years old widow living alone at home, attended her GP, Dr Murphy, complaining of a sore throat and slight fever.

Standard examination led to the diagnosis and management of the presenting uncomplicated URTI.

In the course of this routine examination, Dr Murphy noticed recent bruises on Mary's right shoulder, elbow and ribcage in the mid axillary line.

Mary stated that she had sustained the bruising in a fall 4 days earlier in her kitchen, but was unable to describe exactly how and why she fell, stating simply "I have been feeling tired lately and must have tripped over my own feet".

Having noticed that Mary's walk from the waiting room to the consulting room had seemed cautious and slow, Dr Murphy examined the ribcage, shoulder and knee, and performed the Frailty Phenotype test.

Note : Another quick Frailty screening tests which Dr Murphy could have used is the Get Up and Go (GUG) test.

Other frailty assessment tests include the Rockwood Clinical Frailty Scale, Gait Speed test and PRISMA-7,

however these are more time consuming to administer, and therefore not as easy to incorporate into a standard GP consultation time as the brief screening Frailty Phenotype and GUG tests.

Dr. Murphy reassured Mary that no serious damage appeared to have been caused by the fall, and explained that the GUG test raised the suspicion that Mary was at risk of further falls.

Dr Murphy briefly outlined the importance of investigating falls and screening for osteoporosis.

He requested Mary see the practice nurse Cathy :

Three days later for Frailty screening and Frax scoring
One week later (when recovered from URTI) for ECG and Blood screen

Trigger

Ultimately, the key to introducing and developing a viable system for the CGA based personalised preventative primary care of the eldely is, as always, to first of all delegate tasks

to properly trained and equipped nursing staff,

leaving the GP free to concentrate on clinical examinations and decision-making,

and gradually expanding the supporting team according to locally available resources,

while always retaining the GP as leader and

co-ordinator,

in a continuous cycle of high quality care

which becomes increasingly more sophisticated as the system is streamlined, refined and expanded in keeping with the individual practice's resources and local support system

WORK-UP

Visit 1 (nurse)

Nurse Cathy performed the following functions :

Frailty screening
- Edmonton scale
  - Clock test
  - TUG test
FRAX scoring
- Result : Frax = Low bone mass, leading to request for Dexa *

Visit 2 (nurse)

Nurse Cathy performed the following functions :

ECG
Blood screen
- FBC
- ESR
- LFT
- TFT
- glu + HbA1c
- FSH
- Renal screen with eGFR
- Bone screen with Ca+ uncuffed and Vitamin D
- Coeliac screen with Bence Jones protein and Mg+

Nurse Cathy ended this initial 30 minute appointment with a few words of encouragement about the reversibility of many aspects of Frailty and the possibility of improvement in quality of life.

She handed Mary a copy of one of the 2 booklets in stock which outline this : Young at Heart and Healthy Ageing

Dr. office review of results of :

Frailty screen
- Mary scored 9 on the Edmonton scale = mildly frail
FRAX
- Mary scored 15 = Low bone mass
ECG
- normal
Blood
- low vit D,
- all other results in normal range
This led Dr Murphy to request
- Dexa scan
- Appointment scheduled with nurse Cathy on receipt of Dexa scan results, for QFracture scoring
- Followed by same day review appointment with Dr Murphy

The 2017/18 NHS General Practice Contract

sets out the requirements in England for frailty as follows:

About the NHS General Practice Requirements for Frailty

Use of an application tool such as the Electronic Frailty Index

to identify Frailty in population aged 65 and over

Annual meds review for those registered as living with severe frailty
Promotion of Summary Care Record

FOLLOW-UP

Visit 3 (nurse)

Nurse Cathy performed the following functions :

Q fracture score

Nurse Cathy handed Mary a copy of the 2 booklets with information about VitD and Calcium Food List

and briefly outlined their content.

Visit 3 (Dr review) *

Edmonton Frailty scale
- score disclosed and briefly discussed
- Mary placed on practice Frailty register
FRAX, Dexa Scan and QFracture
- results disclosed and briefly discussed
  - FRAX = low bone mass range
  - Dexa score -2,1 = Osteopenia
  - QFracture : 10 year Hip, wrist, shoulder or spine fracture risk = 26%
    10 year Hip fracture risk = 22%
- Physical examination undertaken : Musculoskeletal, Neurological, Sensation, Feet, Visual, BP sitting and standing
- Mary placed on practice Bone Health register
- Mary referred to Physiotherapist for weight bearing excercise program
- Mary referred to Optometrist for formal assessment
- Mary referred to Chiropodist
ECG result
- reassured ECG normal
Lab results
- reassured all results normal except low vit D
- Mary placed on practice VitD register
Mary informed that her medical records in the practice will be switched to AGEDAT-G1 format for better proactive, personalised care and monitoring, and that she will be requested to attend soon for an extended visit for Nurse Cathy to collect baseline AGEDAT-G1 data
Admin. requested to switch Electronic Medical Record to AGEDAT-G1

Follow-up

Note : because Dr Murphy's EMR system does not allow for free customisaton of the medical record format, switching a patient record to a POMR format such as AGEDAT-1 entails inserting a link into the patient record to a copy of the AGEDAT-G1 Word document file which is manually updated and saved at each consultation.

Note : Switching to the AGEDAT-G1 record is not mandatory.

GPs have the option of continuing with their current EMR system for the recording of consultations and data arising, no matter how simple or sophisticated their protocols are for the provision of elderly care.

About EMR systems

in care of the elderly

Visit 4 (nurse)

Nurse Cathy - AGEDAT-G1 baseline data collection
- Complete al sections except 4-Psychological, 6-Advance Care Planning, and 7-Problem list (to be completed by Dr)

Visit 4 (Dr review)

Review AGEDAT : sections completed by nurse Cathy
- On review of section 5-Social and Environmental Dr Murphy noticed concerns arising re home safety : "I love my 3 cats but they are always under my feet" and "It is getting more and more difficult to get up the stairs at my back-door" and "It is bothersome to have to go downstairs at night to go to the toilet")
- Dr Murphy requested OH home visit for Environmental Assessment
Review AGEDAT : Dr Murphy completed sections
- 4-Psychological - no immediate need for mental state evaluation
- 6-Advance Care Planning - no concerns about capacity
- 7-Problem List - entries made for Frailty, Osteomalacia and Low VitD
Dr Muphy performed a Medication Review
- Stopped : regular codeine containing analgesic
- Started : daily VitD supplement

Monitoring

MONITORING

Mary's will be recalled to the practice for monitoring of her health :

As per AGEDAT-G1
- Yearly
  - Base data review (including : Functional, Psychological, Social and Environmental)
  - Influenza and Pneumonia vaccination when due
  - Height
  - Laboratory screen
- Every 4 months
  - medication review
  - Weight
  - Check : Appetite, Swallow, Elimination bowel, Elimination bladder.
Plus as per personalised changes to the above monitoring care plan
- as may be requested by Dr. Murphy
- or required by the registers where Mary has been listed
  - Frailty register
  - Bone Health register
  - Vitamin D register

SPINOFF

Mary was very happy with the care she received from Dr. Murphy and singing Dr's praises to her family and friends
As a result, Mary's 2 adult children and their family (4 adults and 3 children) transferred to Dr. Murphy's practice
and 5 other elderly patients (2 couples and one widower), all friends of Mary, also transferred to Dr. Murphy's practice

Spinoff

Summary

SUMMARY

Attendance
- Mary attended the surgery 4 times, after the initial trigger consultation
- seeing the nurse 3 times for various tests and once for the completion of the AGEDAT-G1 record
- and seeing the Dr. twice, on both occasions immediately after one of the nurse appointments
- The duration of all visits was within the practice's customary time frame.
Benefits
- Extremely satisfied patient
- Enrolment of 12 new patients to the practice (9 adults and 3 children)

Fees levied for service

In this case scenario, in both the UK and ROI, the 2 GP consultations would not be remunerated over and above the annual capitation rate received for elderly patients entitled to free healthcare.

The practice would bear the cost of the 4 nurse visits.

In the ROI, fees could be levied for the ECG and optional fees for the phlebotomy. Not so in the UK.

There is no extra remuneration in either country for any of the 4 tests administered in the evaluation of Frailty and Bone Health.

There is no remuneration in the ROI for placing patients on chronic disease registers. The Frailty, Vit D, and Bone Health registers are not part of the recognised QOF remunerable registers in the UK, so placing Mary on those 3 registers, while vital to her ongoing care, would also be unremunerated.

Is the identification, investigation and ongoing care of the frail elderly and elderly with a fall risk reasonably funded, directly financially viable and directly sustainable for the GP in the UK and ROI? No, definetely not. The inherent,very real and tangible benefits are indirect.

Setup

REQUIRED SETUP

Dr. Murphy's practice was able to provide the care of the patient described above because it provided the following :

Practice registers
- Frailty register
- Bone Health register
- VitD register
Nurse Protocols
- Nurse(s) trained and furnished with equipment and literature for the performance of the following functions :
  - Frailty screen : Edmonton scale
  - Clock test
  - TUG test
  - AGEDAT-G1 : gathering baseline info.
  - FRAX scoring : online
  - QFracture scoring -:online
  - ECG
  - Phlebotomy
Multi Disciplinary Teamwork and liason with local service providers
- OH nurse : domiciliary visit for environmental assessment
- Physio : personalised excercise plan and postural muscles strengthening
- Optometrist : formal assessment
- Chiropodist : assessment and care
AGEDAT-G1 medical record linked to the practice Electronic Medical Record system (optional).