CGA in community settings

Introduction

The concept of “polypharmacy” is a well recognised phenomenon, forming a keystone of any comprehensive geriatric assessment. We considered whether a similar concept could be applied to the number of outpatient clinics that patients may attend - a concept we have coined “polyclinic”. We recognise that older populations may have a greater number of comorbidities and, as a result, have more healthcare professionals inputting into their care. Similar to the potential detrimental effects of multiple medications, we were interested to explore if a similar detrimental effect may apply to patients attending multiple clinics. We also attempted to consider environmental impacts. We approached this in both a quantitative and qualitative manner.

Method

A cohort was selected from all admissions to a subacute Geriatrics ward at University Hospital of Wales during the month of April 2023. National records were used to review the last decade of clinic attendances. For interviews every 4th patient was contacted

Results

66 patients (75% female) were identified with 3 exclusions. The average number of clinics attended was 18.4 with 0.36 new diagnoses being made per clinic and 0.69 interventions per attendance. Geriatric clinic attendance yielded both a higher average number of diagnoses and interventions (0.93 and 1.4 respectively). Patient feedback was limited to 8 patients and 7 next of kin. Feedback regarding ‘worthwhileness’ was very positive with ratings >8/10. Feelings about possible cutting back on clinics or virtual clinic attendance were mixed with concerns regarding suitability and access to technology

Conclusions 

We identified several limitations to this pilot project,  however, overall feedback gained from patients and next of kin regarding clinic attendance was positive.

This study does not have the scope to suggest that attending multiple clinics are detrimental but aims to raise the concept of “polyclinics” that may be overlooked, particularly in a co-morbid population. We have also considered potential patient impact to multiple attendance and concerns regarding possible changes to traditional face to face clinics. With a climate crisis upon us we also draw attention to environmental impacts for consideration.

Background:

With advancing age comes the increasing prevalence of frailty and increased risk of adverse outcomes (e.g. hospitalisation). Internationally, models of Comprehensive Geriatric Assessment (CGA) delivery in primary care/community settings vary, and effectiveness is uncertain. CGA is a complex intervention and improving the effectiveness and efficiency of it first requires exploration of how individual components may work and how the intervention can be strengthened.

Aims:

To explore how to enhance current CGA, the conditions needed to implement enhanced CGA and the outcomes that older people, families, health and care professionals identify as important. 

Methods:

A qualitative study using semi-structured interviews with older people and healthcare practitioners working in non-hospital settings with older people in the UK. Data were analysed using an abductive analysis approach. Findings were shared with our stakeholder group involving older people, family members, health and social work professionals.

Results:

Twenty-seven people participated including 14 older people and 13 healthcare professionals. We identified limitations in current CGA: the lack of information sharing between different healthcare professionals who are delivering the CGA; communication between older people and their healthcare professionals; and follow-up after conducting the CGA. There was variation in participant perceptions on the provision of digital and remote assessment. However, we found that introducing remote assessment and a designated comprehensive care coordinator might be a viable solution to address the gaps in the current delivery of CGA.

Conclusions:

The study identified potential challenges in the implementation of enhanced CGA. However, the participants suggested possible solutions that can be used to overcome these challenges, which aligned with feedback from relevant stakeholders. The next stage of this research will involve using these findings, alongside existing evidence and key stakeholder engagement, to develop and refine a model of enhanced CGA that can then be assessed for feasibility and acceptability.

Introduction: According to the Health Education England (HEE) Framework for Enhanced Health in Care Homes 2020, 33% of people over 65 and 50% of people over 80 have one or more fall a year, figures which significantly increase in care home residents. Prevention of falls promotes the quality of life of elderly patients and could significantly reduce the burden on primary and secondary care stemming from fall induced fractures, loss of mobility and community follow up. The Comprehensive Geriatric Assessment (CGA) for falls includes a full falls assessment questionnaire, medication review, lying/standing blood pressure and frailty index. The HEE set out a requirement that all care home patients should have a CGA assessment within 7 days of readmission to a care home following a hospital episode because of a fall. This audit examined the compliance of Four Counties primary care network (PCN) to the 7-day CGA HEE guideline for falls. Methods: Retrospective analysis of 68 eligible patients from Four Counties PCN between 31st March 2021 and 1st March 2022. Analysis indicated a poor compliance to the HEE CGA guidelines (15%). After presenting to the MDT, we formulated a system-wide plan to improve reporting of care home falls to OTs, creating protected time for pharmacists to conduct care home medication reviews and promoting in-person weekly care-coordinator meetings. The PCN was audited for a second time after 3 months. Results: A significant improvement (15% to 57%) in adherence to the HEE CGA framework was noted after implementation of above changes. Medication review in 7 days improved from 42% to 80% and falls assessment questionnaire in 7 days compliance improved from 23% to 70%. Conclusion: Creating clear protocols for reporting falls and clarifying MDT roles in the CGA are essential to identifying and preventing falls in at-risk care home residents.

Introduction: Frailty is a long term condition with potentially significant associated healthcare costs and resource usage. The gold standard evidence based intervention is a comprehensive geriatric assessment. The NHS Long Term Plan highlights the importance of ageing well and developing proactive services in the community. Care home residents often have unmet health and social care needs, and are frequently frail. Methods: 59 patients with severe or very severe frailty (Rockwood clinical frailty score 7 or 8) across three care homes with both residential and nursing provision were reviewed in person. They were then discussed in an MDT comprised of geriatricians, GPs, community matrons, district nurses, community therapists and care home staff in order to complete a virtual CGA resulting in a personalised care plan. Results: In the 8 weeks after MDT, compared to the 8 weeks before, there was a 49% reduction in GP contacts (28 vs 55) and a 17% reduction in ED attendances (5 vs 6). There was a 133% increase in proactive referrals (7 vs 3) and 20 advanced care plans were completed. 74 medications were reduced or stopped whilst 4 medications were started, with a cost saving of £812.58 over the 8 week follow up. Conclusions: Despite a small sample size and a short follow up period, these results suggest that intervention with a proactive CGA provides benefits to frail care home residents, particularly with regards to reductions in polypharmacy and improved access to advanced care planning. These results also suggest potential benefits to the wider system, with reductions in GP contacts and unplanned hospital attendance. We suggest that in future a CGA should be completed for each new resident to a care home as the basis of a personalised care plan.