Proactive Care of the Eldely

Resources for the Comprehensive Geriatric Assessment based

Proactive and Personalised Primary Care of the Elderly

Proactive Care

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.

GST-4

Gait Speed Test (4 metre)

Simple assessment of functional mobility

5 min.

PRISMA-7

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

Assessment of presence of frailty

5 min.

Brief CGA Template

Data collection template for the initial abbreviated Comprehensive Geriatric Assessment

x min. variable

AGEDAT

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