CGA in community settings

Introduction  - Swansea Bay Health Board is covered by eight community clusters (240 virtual beds), each with their own Virtual Ward (VW) MDT which provides community based Comprehensive Geriatric Assessment and reablement. The VW governance structure includes the routine collection of person centred metrics. There is no recognised PROM or PREM specifically designed for needs of frail older people and PROMs and PREMs are rarely used to inform quality and continuity in services at transitions of care (e.g. at discharge from hospital)

Methods - VW data from June 2023 to February 2024 was analysed. Patient-reported outcomes and experiences (PROMS and PREMS) were collected by the VW team at set timepoints in the patient journey. Data was collected using the PRO-MAPP digital interface ensuring inter-user consistency.

Results - 1858 VW patients, 1094 (58.9%) female, median age 86 years. The majority, 1044 (56.2%) were referred from secondary care, primarily from acute frailty services, with the remainder identified by primary care. In total, 418 PROMS and 344 PREMS were collected. PROMS - Reported improvements in mobility, self-care, usual activities, pain and anxiety & depression (p001 after vw input. prems – the majority of patients found had been explained well prior to referral (84.0%), were contacted promptly (95.6%), staff professional and friendly (100%), provided patient-centred care (94.2%), contactable (92.4%), glad they avoided or reduced length hospital admission (95.3%). when speaking with 72 care-givers, happy patients' needs met (100%) positively impacted their lives as carers (90.1%).

Discussion - there was high patient care-giver satisfaction service. prom data suggested a significant positive impact on outcomes. not all referred have sampled which is missed opportunity variability between collection clusters. 

Introduction

Community-based comprehensive geriatric assessment (CGA) reduces hospital admissions but the optimal way in which CGA can be delivered is not well understood. Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) is a programme of research seeking to develop an enhanced community CGA intervention.

We aimed to identify candidate cognitive assessment tools (CATs) that could be undertaken remotely and enhance CGA.

Methods

Searches were carried out on Medline, PsycINFO, CINAHL and Cochrane databases. Papers published since 2008 were included if they analysed the validity, reliability or acceptability of CATs that could be undertaken remotely in a domestic setting and were tested on older people.  

Results

Of 4286 papers identified, 56 were included. Four types of CAT were identified: computer/tablet/smartphone applications (23tools/27papers), telephone (16tools/23papers), video (2tools/2papers) and specialist equipment (4tools/4 papers). 14 tools demonstrated excellent accuracy for identifying mild cognitive impairment or dementia (specified as AUC >0.80 or sensitivity/specificity>80%). 42 papers presented concurrent/convergent validity, 14 reliability and 16 acceptability data. Time taken to perform tests ranged between 2-30 mins. Of the 23 computer/tablet/smartphone applications, 7 tools are currently available to download.

Key conclusions

Remote CATs could be used in CGA.  Computer/tablet/smartphone applications and some specialist equipment could enhance assessment by quickly and accurately identifying cognitive impairment, in some cases with greater accuracy than traditional tests. Tools that use ‘games’ may be more appealing than conventional pen and paper tools. ​However, many of the computer/tablet/smartphone applications tested are not available for clinical use.

Introduction:

The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents. We established a multi-disciplinary care home team providing comprehensive geriatric assessment (CGA), structured medication review (SMR) and advance care planning (ACP) to a pilot cohort of frail residents in 17 care homes. We aimed to explore the acceptability and perceptions of proactive ACP alongside CGA from the perspective of resident’s next-of-kin (NOK), primary care staff and care home managers (CHMs).

Methods:

Data was collected using standardised questionnaires between February-September 2022. Data were analysed using qualitative content analysis. This was undertaken independently by two lead authors, after which codes and categories were identified through a collaborative approach and triangulation.

Results:

Four categories emerged from NOK data: 1) Perceived benefit of frailty specialist review, 2) Perceived improved knowledge of the individual through holistic assessment, 3) Sensitive conversations were perceived to have been handled well, but this was sometimes challenging over the phone, 4) Families felt empowered in shared decision making. Six categories emerged from primary care feedback: 1) Perceived benefit of holistic reviews, 2) Improved information sharing using same clinical system, 3) Specialist frailty involvement supporting GP learning, 4) Challenges with set-up, 5) Perceived avoidance of admissions following reviews, 6) Time and financial savings for NHS Four categories emerged from CHM feedback: 1) Perception that medical reviews were overdue, 2) Reduced care home staff workload through saving of time, 3) Specialist review and 4) Empowering staff to avoid admissions.

Conclusions:

This evaluation identified key feedback themes in relation to the perceived value and acceptability of a dedicated care home team performing CGA based ACP. Stakeholders expressed positive views about the service, suggesting benefits for individual residents, primary and community healthcare staff, and the wider healthcare system.

Introduction: 

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention:

1) GPs clinically assessed all CH residents for frailty.

2) Proactive i-CGAs completed using our IT-assisted CGA tool, which prompts to review/consider/address:

• Previous i-CGA-related entries
• Traditional CGA-domains/risks
• High-risk drugs/deprescribing
• ACP discussions (hospitalisation/resuscitation/place of death preferences)

3) ACPs shared with relevant healthcare services/Out-Of-Hours.

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

• i-CGA (1-year post-i-CGA completion)
• Control (1-year post-frailty diagnosis, no i-CGA, usual care)

Results:

i-CGA group: 196 residents(16 mild, 69 moderate,111 severe frailty)

Control group: 100(13 mild,31 moderate,56 severefrailty ).

No significant baseline differences.

Advance care planning:

• i-CGA: 100% residents had documented resuscitation decisions. 97% (191/196) preferred to "allow a natural death. Patients with severe frailty: 85%(94/111) preferred not to be hospitalised. 55%(52/94) died, 90%(47/52) in their CH.
• Control:  72%(72/100) had documented resuscitation decisions or which 97% in this group (70/72) preferred to "allow a natural death". Patients with severe frailty: 29%(16/56) had no hospitalisation preferences documented and in this group 25%(4/16) died in hospital.

Hospitalisation in residents with severe frailty:

• i-CGA: compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive.
• Control: Unplanned hospitalisations increased:0.87 to 2.05/person years alive.

Survival: significant group mortality difference was seen at one year: 55%(62/111) severely frail i-CGA residents died compared to 77%(43/56) controls, p=0.0013.

Conclusions:

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.