1. CGA in Primary Care Settings: Introduction
An introduction to Comprehensive Geriatric Assessment (CGA) in primary care settings. This toolkit was developed by the British Geriatrics Society for professionals in primary care and has been endorsed by the Associate National Clinical Director for Older People and Integrated Person-Centred Care for NHS England and by the British Geriatrics Society Scotland Council.
What is CGA?
Comprehensive Geriatric Assessment (CGA) is a process of care comprising a number of steps. Initially, a multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant). Interventions are then arranged in support of the plan. Progress is reviewed and the original plan reassessed at appropriate intervals with the interventions reconsidered accordingly.
Some bodies prefer to call it a comprehensive older age assessment (COAA). It is also referred to as geriatric evaluation management and treatment (GEMT). It is a form of integrated care and is an example of a complex intervention.
Why is it done and who does it?
Evidence shows that CGA is effective in reducing mortality and improving independence (still living at home) for older people admitted to hospital as an emergency compared to those receiving usual medical care.
In community settings, the evidence shows that complex interventions in people with frailty can reduce hospital admission and can reduce the risk of readmission in those recently discharged.
CGA is also a vital part of the management strategy for older people suspected of having frailty in order to identify areas for improvement and support to reduce the impact of frailty.
A recent study showed that comprehensive assessment and individualised care planning can reverse the progression of frailty.
Who does CGA?
The CGA process requires coordination to ensure that the experience is positive for both the patient and their families. As older people’s needs are frequently complex and always unique those coordinating the process must display advanced communication skills in addition to their clinical knowledge to ensure purposeful and timely assessment. Therefore coordination of CGA can be undertaken by any member of the health and social care team but is best carried out by someone the patient and their family trusts and with whom they can have open and sensitive discussions.
In many cases this will be the patient’s GP – especially if they have known the patient for some time and have been involved in other aspects of their care. GP’s in particular will be well placed to handle a medication review in the context of the overall person-centred goals. Although this could be delegated to a pharmacist, it will not be valuable unless performed as part of CGA.
Nurses are well placed to manage the complexity of assessment in an efficient way drawing together the different strands to coordinate a personalised treatment plan in which the patient and their family share their aspirations and choices. Nurses have a duty to act as patient advocate, empowering people to make shared decisions; these roles are set out within their standards of conduct, performance and ethics.
In cases where there is particular complexity, or where there are concerns about underlying diagnosis or treatment options, a geriatrician working in a community setting could be involved in, or even lead, CGA.
When is CGA done?
CGA should be considered appropriate in a number of circumstances, all of which reflect frailty in an individual (for more detailed information see Fit for Frailty Part 1 2014):
- When an older person presents to their GP with one or more obvious frailty syndromes – i.e. falls, confusion, reduced mobility and increasing incontinence even if these appear to be due to a reversible cause – such as a new medication or minor infection or if the ambulance service has already been called – it is unlikely they will have started the process of CGA.
- When a GP or community team learns of an incident which implies frailty in an individual - for example if an ambulance is called after a fall.
- When an older person has been discharged from hospital after presenting with a frailty syndrome (fall, reduced mobility, delirium etc) even if another diagnosis has been offered as the cause. Sometimes a simplistic, and occasionally erroneous, diagnosis such as Urinary Tract Infection- UTI appears to have caused a prolonged admission and this implies significant frailty. In this situation, the process of CGA might have been started in hospital – but it will need to be refreshed once the older person is back in the community in a more steady state.
- In care homes - most residents of care homes (both those with and without nursing care) will have frailty. The process of CGA will help to identify the future treatment goals and support the necessary advance care planning.
CGA should form part of the process of proactive care and would therefore be also focused on a target population - possibly those with moderate frailty identified through risk stratification. Different federations of GP’s in England will be considering their strategies for managing this approach- currently there is no well defined ‘best’ practice and there is no hard research evidence that systematic screening for frailty offers any economic benefit. Nonetheless the unplanned admissions enhanced services in primary care require consideration of risk stratification.
Several tools for risk stratification and for frailty ‘screening’ are available and more are being developed. One new tool which may help with risk stratification is the Electronic frailty index eFI. This tool, which is now available in both TPP system one and EMIS web, uses Read codes embedded within the records to compute a score for an individual (it therefore has the obvious disadvantage of relying on good coding). Local decisions can be made as to the cut-off points within this range for mild, moderate and severe frailty. Likewise local plans will be needed as to the pathways to follow once an individual’s scores are available. There are other examples of clinicians using their knowledge of their own practice population to highlight people who need more detailed assessment.
Where is CGA done?
Since the process of CGA can be performed anywhere, either in the older person’s home, in the GP surgery or in a special clinic set up for the purpose in a leisure centre, day centre or hospital outpatient department. The exact situation is less important than the process and activity. It should form part of the care in an acute setting.
It is also ideally suited for the process of proactive care in community settings – however the nature of community working including the geographical and availability challenges for many members of a multi-professional team means that the process will need to be adapted as outlined in ‘How is it done?’ (see next page in this Good Practice Guide series).