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

Proactive Care

Proactive Care Team, CGA based Proactive Primary Care of the Elderly

Older people living with frailty make up between 9% and 25% of the population. They are the highest users of services across health and social care and have the highest levels of unplanned admissions to hospital. Yet we know that between 20% and 30% of the admissions in this group could be prevented by proactive case finding, assessment, care planning and use of services outside of hospital (Mytton OT, 2012).

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Clinical Frailty Scale - Rockwood

Rockwood Clinical Frailty Scale

Frailty evaluation tool

5 min.


Gait Speed Test (4 metre)

Simple assessment of functional mobility

5 min.


Program of Research to Integrate Services for the Maintenance of Autonomy - 7

Assessment of presence of frailty

5 min.

Brief CGA Template

Brief CGA Template

 Data collection template for the initial abbreviated Comprehensive Geriatric Assessment

x min. variable


Annual GEriatric Data Template

Annual notes template for the full Comprehensive Geriatric Assessment

x min. variable

My Health Plan - int'l

My Health Plan - international version

Personalised Care Plan template

x min. variable

To deliver proactive care to its frail/elderly patients a GP practice will need to effectively and cost efficiently engage in :


1. Case finding and populating/maintaining a Frail/elderly register

2. Assessment
3. Case management



1. Case finding and populating/maintaining a Frail/elderly register


Select and implement appropriate strategies  for Identifying the frail/elderly in need of care, and then populate/maintain a Frail/elderly register

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2. Assessment


The 3 core aspects of assessment are :

  • Completion of brief CGA and generation of a problem list.

  • Holistic medical review aimed at optimising management of long-term conditions and referral to other disciplines if needed. Underlying diagnoses and reversible contributors to frailty should be addressed.

  • A full medication review using STOPP START methodology.

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3. Case Management


Individual case mananagement includes :

  • Individualised goal setting in collaboration with the patient and carers if appropriate.

  • Generation of a personalised care plan using the national ES template based on identified goals.


    Selecting the appropriate care process,  may include :

  • a more in-depth CGA, if medical problems dominate, and who will be involved in carrying it out.

  • changes in medication and joint care arrangements with carers and pharmacist

- optimisation and implementation of  self-management  measures

- specialist intervention for specific medical needs

-  third-sector/community care and support for issues such as social isolation and loneliness

-  social services care and support  for social and environmental needs

-  Advanced Care Planning support

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ECG with PVCs

The Annual Physical in Proactive Care

GoTo :The Annual Physical in Proactive Care

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