Abstract
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.