Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Proactive Care
Older people living with frailty make up between 9% and 25% of the population. They are the highest users of services across health and social care and have the highest levels of unplanned admissions to hospital. Yet we know that between 20% and 30% of the admissions in this group could be prevented by proactive case finding, assessment, care planning and use of services outside of hospital (Mytton OT, 2012).
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Clinical Frailty Scale - Rockwood
Rockwood Clinical Frailty Scale
Frailty evaluation tool
5 min.
GST-4
Gait Speed Test (4 metre)
Simple assessment of functional mobility
5 min.
PRISMA-7
Program of Research to Integrate Services for the Maintenance of Autonomy - 7
Assessment of presence of frailty
5 min.
Brief CGA Template
Brief CGA Template
Data collection template for the initial abbreviated Comprehensive Geriatric Assessment
x min. variable
AGEDAT
Annual GEriatric Data Template
Annual notes template for the full Comprehensive Geriatric Assessment
x min. variable
My Health Plan - int'l
My Health Plan - international version
Personalised Care Plan template
x min. variable
To deliver proactive care to its frail/elderly patients a GP practice will need to effectively and cost efficiently engage in :
1. Case finding and populating/maintaining a Frail/elderly register
2. Assessment
3. Case management
1. Case finding and populating/maintaining a Frail/elderly register
Select and implement appropriate strategies for Identifying the frail/elderly in need of care, and then populate/maintain a Frail/elderly register
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2. Assessment
The 3 core aspects of assessment are :
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Completion of brief CGA and generation of a problem list.
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Holistic medical review aimed at optimising management of long-term conditions and referral to other disciplines if needed. Underlying diagnoses and reversible contributors to frailty should be addressed.
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A full medication review using STOPP START methodology.
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3. Case Management
Individual case mananagement includes :
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Individualised goal setting in collaboration with the patient and carers if appropriate.
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Generation of a personalised care plan using the national ES template based on identified goals.
Selecting the appropriate care process, may include :
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a more in-depth CGA, if medical problems dominate, and who will be involved in carrying it out.
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changes in medication and joint care arrangements with carers and pharmacist
- optimisation and implementation of self-management measures
- specialist intervention for specific medical needs
- third-sector/community care and support for issues such as social isolation and loneliness
- social services care and support for social and environmental needs
- Advanced Care Planning support
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The Annual Physical in Proactive Care
GoTo :The Annual Physical in Proactive Care