Hospital Wide Comprehensive Geriatric Assessment (HoW-CGA): Overview
Frail older people admitted for acute inpatient hospital care are at high risk of adverse events, long stays, readmission and long term care. Comprehensive Geriatric Assessment (CGA) improves outcomes for this group, particularly on specialised wards. However, there is uncertainty about how best to do this across the whole hospital.
Overview
This work was funded by the National Institute for Health Research, and produced in partnership with the British Geriatrics Society and the Ageing Speciality Group of the Clinical Research Network. It forms part of a series. See the full series here
Background
Frail older people admitted for acute inpatient hospital care are at high risk of adverse events, long stays, readmission and long term care. Comprehensive Geriatric Assessment (CGA) improves outcomes for this group, particularly on specialised wards. However, there is uncertainty about how best to do this across the whole hospital.
The aim of this project was to provide high quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA). The objectives were to:
- Define CGA, its processes, outcomes and costs in the published literature
- Identify the processes, outcomes and costs of CGA in existing hospital settings in the UK
- Identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK
- Develop tools which will assist in the implementation of hospital-wide CGA.
We used mixed methods including a mapping review, national survey, large data analysis, and qualitative methods, focusing upon people aged 65+ in acute hospital settings.
Survey results
There was a highly variable provision of multidisciplinary assessment and care across hospitals. 58/175 (34%) trusts returned survey, and provided 121 service descriptions. CGA provision across inpatient settings varied, with some areas (e.g. orthopaedics, older people’s medicine and stroke) more completely provided with multidisciplinary teams than others (surgical and oncology). Most services (108/121, (89%)) relied on clinical assessment processes to identify patients; 26% used a standardised method to identify frailty. Around 90% of services assessed cognition, activities of daily living, mobility, falls risk, medications, nutrition, continence and skin integrity routinely.
Developing and testing clinical toolkits
A multi-level approach was used.
- Strategic (regional) level: aimed at System Resilience Groups (SRGs) and leads of Sustainability and Transformation Plans (STPs); content included data on higher-than-expected attendance/admission rates, length of stay, readmission rates and institutionalisation among frailer individuals.
- Operational (acute trust) level: aimed at operational managers; content included national reports and data from this project to identify opportunities for improvement.
- Service-level: aimed at clinical teams; content included improvement guidance, a self-assessment tool to identify what processes need development, and supported by clinical, improvement and evaluation tools.
- Patient and carer level: aimed at empowerment to take a more active role in their care. Content included guidance on influencing acute service provision and information to increase awareness.
In total we undertook 28 hours of observational work and 52 interviews across three pilot services. In Sites 1 and 2, clinicians involved in surgery agreed to use the CGA toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively to improve patient experience and outcomes. Sites ultimately concluded that pre-operative assessment was not the best place for the CGA, and at the end of the 12-month trial, Sites 1 and 2 were still at the start of implementation. Clinicians understood that the new model of care could improve outcomes. The entanglement of CGA with ideas about holistic care and improving all patients’ experiences meant that the specific focus of CGA and frail older patients was partly side-lined. A final challenge was limited time, attention and resources, compared to completing day-to-day business.
In Sites 1 and 2 the toolkit could not operate as a ‘standalone’ intervention, without support from geriatricians. In site 3, the geriatrician took an active role, using the toolkit with the surgical lead to complete an informal assessment of current practice and competencies available, and to introduce CGA to clinicians. But it was unclear to what extent the toolkit further influenced practice.
Sites 1 and 2 identified that clinical specialisms, e.g. pharmacy, physiotherapy, dietetics, nutrition, social work, and discharge planning, could contribute to holistic care and started thinking how to create these ‘missing’ links. But these efforts were competing against the dominance of national time-limited targets for treatment.
Geriatrician availability to work with the site teams regularly for a sustained period seemed critical, and it seems likely that initiatives would have progressed little without this. The geriatric support was a driver, but also an important source of ambiguity. While the participating geriatricians were able to find time to support the teams during the pilot, it was not clear that this was sustainable. In effect, despite their initial differences in aims, the teams in Sites 1 and 2 converged on setting up a liaison service where a geriatrician was seen as crucial in offering help to those responsible for coordinating existing pathways.
Conclusions
Comprehensive Geriatric Assessment remains the gold standard approach to improve a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful, but require prolonged geriatrician support and implementation phases.