22COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) FROM SECONDARY TO PRIMARY CARE: A PILOT STUDY OF AN INTER-PROFESSIONAL APPROACH WITHIN A LOCALITY BASED MODEL OF CARE

Abstract

Topic: Comprehensive Geriatric Assessment (CGA) is fundamental to developing a coordinated and integrated care plan for long term treatment, follow up and is useful for planning care of those living with frailty. Intervention: An inter-professional approach to CGA in the acute setting was developed. Seven patients living with frailty and who had recurrent hospital admissions were identified. CGA was led and project managed by a nurse practitioner and involved other health professionals. The patients and their caregivers were pivotal in identifying individual health, social and psychological needs allowing personal goal setting and anticipatory care planning. The care plan was then shared verbally and electronically with the specific locality virtual ward. Ongoing dialogue with the community team ensured the care plan was followed through and a follow-up home visit four weeks post discharge enabled the care plan to be revisited and goals re-set as necessary. Admission data was collected at baseline, during readmission and between 6-9 months. Improvement: Both the acute and community teams had increased and coordinated knowledge of patient's health and care needs resulting in better communication and planning. There were fewer readmissions within 6-9 months of CGA with three patients not readmitted acutely. During their readmission, patients generally spent fewer days in hospital compared to their length of stay (LOS) peri-CGA (table 1). Table 1 Results at 6-9months; and Table 2 Results at 1 year Discussion: Having a focused inter-professional and holistic approach to care planning improved the experience of accessing health and social care from the perspective of an older person living with frailty in this study. Increased knowledge of individual patients, better communication and care planning between secondary and primary colleagues positively impacted on length of stay during readmission. Avoidance of inappropriate hospital admission with additional support at home can improve frailty markers and there is scope to develop this work further with a larger sample size. (Table Presented).