This document replaces the compendium document "Community Geriatrics" and "The Role of the Geriatrician in the Community"

The considerable demographic shifts in the last decade, together with advanced technology, have resulted in district general hospitals and teaching hospitals becoming focused almost entirely on providing intensive input for acutely ill people of all ages. This has led to general practitioners and the primary care team increasingly being responsible for groups of older people who, in previous times, would have been cared for by specialists.

The British Geriatrics Society believes that all departments catering for older people in hospital ,should provide comprehensive service in the community to support general practitioners and primary care teams caring for older people.

A. Defining the Work of the Geriatrician Outside an Acute Hospital Setting

1. Health Promotion / Primary Prevention

The role of the geriatrician in this area needs to be purely advisory.

2. Secondary Prevention or Secondary Disease Management / High Risk Patients

Patients in this group benefit from supported self-care, specialist disease management and case management, as recognised by the recent publication of the NHS Improvement Plan [1].

Most patients will be seen in primary care, but a stepped care model is recommended as the ideal process so that patients can be stepped up, and stepped down, according to individual needs and preference [2].

3. Intermediate Care

The system of intermediate care recommended by the British Geriatrics Society, forms part of compendium document 4.2 (currently under review).

4. Management of Long-term Conditions

It has recently been recognised that to provide ideal care for older people and/or patients with chronic disease, specialist nurses need to work alongside both general practitioners and consultants in managing those patients with complex problems, in both hospital and community settings. The same authors also recognise that there has been little integration between primary and secondary care. [2]

The British Geriatrics Society recommends that community geriatricians be promoted to support this process. It also recommends that the training of geriatricians be reviewed and that CPD be examined for this role. The community geriatrician should take a lead on the multi-disciplinary education and management of staff involved in these services.

B. Observing the patient’s fundamental rights

It is the fundamental right of patients with long term conditions and or frailty, to access appropriate types of treatment. Departments of Geriatric Medicine should be organised in such a way to provide these services in a flexible collaborative fashion, wherever the patient lives [3].

These patients have the right to acute treatment, a comprehensive assessment and review, rehabilitation and enablement as well as palliative care.

C. Managing long term conditions in care homes

The British Geriatrics Society supports the development of proactive care for the frail older residents of residential and nursing homes.

Older people in care homes need to be recognised by practitioners as a discrete population and a case management system should be set up to meet their needs.

Specialist geriatric medicine and old age psychiatry should be re-engaged in a structured manner to the care home population, as recommended in the consensus statement in 2004.

Specialists will support the team approach to care in homes.

D. Continuing Care

Regardless of the source of funding, no individual should enter a system of domiciliary or institutional care without prior exposure to an effective system of specialist and multidisciplinary assessment, backed up by appropriate treatment and rehabilitation.

Partnerships should be set up between, district nursing, primary care, general practice, therapies, old age psychiatry and geriatric medicine, to recognise and meet the needs of vulnerable older people receiving continuing care.

E. Qualities Required by Community Geriatricians

Geriatricians will need to provide professional support for assessment processes used on older people, and regular support to primary care trusts and hospital boards regarding performance.
Community geriatricians will need to work closely with general practitioners and specialist nurses and all therapists, advising on treatment and lifestyle alterations in a manner that nurtures the multi-disciplinary team.

They will provide clinical governance leads for services outside the hospital.

They will provide leadership in teaching and research in collaboration with Departments of Primary care

Professionals working in this area will need to work from a shared care and information system.
A case manager will be required to coordinate the system.

F. Comprehensive Geriatric Assessment

Comprehensive geriatric assessment and review of patients in the community is the foundation for effective care of older people [4]. Comprehensive geriatric assessment is defined as a multi-dimensional multidisciplinary diagnostic process that aims to determine a frail, older person’s medical, psychosocial and functional capacities and problems.

The assessment tries to diagnose and screen for treatable illnesses and formulate a rational therapeutic plan, as well as documenting change over time in older people.

Comprehensive geriatric assessments can take place in different settings, and should be performed at each level of older patient care.

The domains which have been identified by the World Health Organisation as needing assessment in older patients include physical health, mental function, cognitive and psychiatric symptoms; functional capacity for the basic activities of daily living and instrumental activities of daily living: social resources, environmental resources and economic resources.

Comprehensive geriatric assessment has been shown to improve functional status, reduce medications, nursing help and medical services, and reduce mortality rate.

References:

1. Supporting people with long term conditions : an NHS and Social care Model to support local innovation and integration. Department of Health: Jan 2005
2. Gask. L, Role of specialists in common chronic diseases. BMJ 2005; 330:651-3
3. Geriatricians and the management of long term conditions. Report of the Primary and Continuing care SIG; 2005
4. Stuck AE, Siu AL, Wieland GD et al . Comprehensive assessment : a meta analysis of controlled trials. Lancet 1993, 342; 1032-6