Abstract
Introduction: Completing a comprehensive geriatric comprehensive assessment (CGA) should be standard practice (Stuck & Lliffe, 2011). Studies have shown some improvement in CFS status following completion of a CGA (Chia-Ming et al., 2010). However, the evidence of community based completed CGA’s in improving health outcomes is limited (Sum et al., 2022).
Background:In November 2023, with the creation of Porth Preseli (PP), members of the frailty pathway joined PP as a pilot, working within an integrated care team (ICT) to provide an Multidisciplinary approach (MDT). No additional resources were required to staff this pilot from frailty.
The Team: Frailty ICT:
GP Clinical lead, Advanced Nurse Practitioner (ANP), Physician Associate (PA). Frailty register 2 sessions/week. Further support from Geriatrician consultant through weekly case discussions and telephone advice.
Aim: To manage frail patients within the community and to prevent hospital admissions.
Objective: To provide acute frailty assessment, management, treatment and completions of CGAs/ACPs in the community.
Referral criteria: Patients presenting with a CFS 5 or more and at least one of the following:
- A Frailty syndrome
- Recent discharge from frailty pathway
- Requiring acute frailty assessment/CGA/ACPs
Data: Collected from all patient interactions from the Frailty ICT within PP from Nov 2023-July 2024.
Results: 108 patient interactions. Referrals from: Frailty pathway 57, WAST 8, ICT Hub 39,GP 3, Clinical Nurse specialist (CNS)/Heart failure (HF) Nurse 1.
Reason for referral: Falls 15, General Decline 7, New medical reviews 20, Facilitating discharge 24, Medication review 4, ACP 22, Symptom reviews 6, Frailty review/GCA 31, Family contact 4, Capacity assessment 1, Social concerns 2.
Outcomes: 31 GCAs completed. No acute admission. Frailty STARS (Short term reablement service: Frailty SDEC) follow up 1, future admissions 4. RIP 6 (4 home, 2 WGH).
Out of the 108 overall interactions, 22 ACP interactions:14 ACPs were completed. 7 Passed away at home/Care home.
Conclusion: Overall positive outcomes. Out of 31 CGAs, avoided 26 hospital attendance/admissions. Keeping patients home with the hospital at home approach, with the further support from ICT. Enacting on patients preferences through the completion of ACPs. Frailty is complex and it is important to have a holistic MDT approach. Improving assess to other services/support.
Challenges identified: Understanding around CFS and CGA, appropriateness of referrals, patient compliance, geographic location/rural, small team, transport.
What is next: Cascade the information we have found. Educate others regarding frailty ICT/CGAs/CFS and appropriateness of referrals. To ensure we keep completing CGAs, being constituent. Educating others regarding the importance of CGAs. Provide further frailty support in care homes e.g ACPs are in place in the care home. Encourage members of the frailty team to rotate through to the Frailty ICT, to utilise everyone’s experience and as it will help them understand what we do in the community. Further interaction with WAST (Welsh ambulance) and support with acute falls/acute frailty syndromes to help avoid conveyance to hospital. Networking with primary/secondary/third sector services. Data collection in the future.
References
Chia-Ming, L., Chin-Ying, Chen., Chun-Yi, Li., Wei-Dean, Wang., Shwu-Chong, Wu.(2010).The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial. Archives of Gerontology and Geriatrics, 50 (1), S39-S42. https://doi.org/10.1016/S0167-4943(10)70011-X
Stuck, A., & Lliffe, S. (2011). Comprehensive geriatric assessment for older adults: BMJ, 343:d6799. https://doi.org/10.1136/bmj.d6799
Sum, G., Nicholas, S.O., Nai, Z.L., Ding, Y.Y., Tan, W.S. (2022). Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review. BMC Geriatrics 22, 379. https://doi.org/10.1186/s12877-022-03024-4