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).

Rockwood Clinical Frailty Scale
Frailty evaluation tool
5 min.
Gait Speed test
Frailty evaluation tool
5 min.

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



2. Assessment
The 3 core aspects of assessment are :
-
Completion of brief CGA and generation of a problem list.
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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.
3. Case Management
Individual case mananagement includes :
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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
PRISMA7
Frailty evaluation tool
Brief CGA Template
Initial abbreviated Comprehensive Geriatric Assessment
5 min.
x min. variable
Screening Tool Of Older People's Prescriptions (STOPP)
Screening Tool to Alert to Right Treatment (START)
Decision aid for supporting medication review. It consists of a series of medications to avoid related to common problems in prescribing for older people generally, and in relation to particular medical conditions. Several of the medications are specific to the USA.
Personalised Care Plan Template
My Health Plan - NHS
5-30 min.
x min. variable
Angelo's GEriatric Data Annual Template v.1
Annual notes template for the full Comprehensive Geriatric Assessment
x min. variable
Read More about Proactive Care
Read More about Case finding and populating/maintaining a Frail/elderly register
Read More about Assessment
Read More about Case Management

The Annual Physical in Proactive Care
GoTo :The Annual Physical in Proactive Care
