2. CGA in Primary Care Settings: The elements of the CGA process
An overview of how Comprehensive Geriatric Assessment (CGA) is done in the primary care setting, and what to consider when conducting the assessment. Further guides in this series examine the functional assessment and psychological components of CGA.
Comprehensive Geriatric Assessment comprises interdisciplinary and interagency working which places the patient and their supporters at the heart of care.
Such an approach is usually proactive and is logically most relevant when it generates an individual problem list identifying issues and how they have changed over time in a number of domains:
a. Physical assessment
b. Functional, social and environmental assessment
c. Psychological components
d. Medication review
It will then accommodate the individual’s own personal goals before documenting interventions and overall management strategies, as well as who will deliver these i.e. a comprehensive care plan.
Depending on the goals/problem(s) identified, the intervention may consist of one or more actions to be delivered by a clinician - doctor and/or other relevant members of the multidisciplinary team (e.g. nurse, physiotherapist, occupational therapist etc), who are included as necessary. The key issue is the collaboration between patient/family/carers and the various members of the team throughout the process. The expectation is that the older person and their family will own this process and regard the resulting care plan as their own. Some of the actions/interventions may rely on activity by the older person themselves.
The holistic nature of CGA covering physical, psychological, functional, social and environmental needs of older people may be confusing if not managed effectively. This is particularly true within the community setting where services are affected by local geography and availability- therefore CGA needs careful coordination.
Making CGA work
Key processes and structures which support implementation and maximise the impact of using CGA:
- Development of multi-professional teams
- Clear identification of a joint core level of competence in assessment between health and social care practitioners
- Clarity of when referral for specialist single professional assessment is appropriate
- Single patient-held documentation
- Information sharing systems
- Regular multidisciplinary team (MDT) review meetings to share knowledge and develop team working
- Access to joint health and social care funding.
Time and financial constraints
Undertaking CGA takes time. To complete the process fully may take up to two hours. Such an undertaking is difficultfor individual GPs working in the current model of care where appointment times are short and time in the day very limited. We would envisage the assessment being contributed to by a number of health and social care professionals and there may be a role for the voluntary care sector to be involved. Some sections can be completed by the informal carer. The information would accumulate over time. Developing a model of proactive care for those Older Adults living with Frailty would enable a multidisciplinary approach to comprehensive assessment for those most at risk of unplanned hospital admissions.
Developing a multidisciplinary approach to proactive care will require new models of care – enabling greater integration between primary care and community providers, social care and the voluntary care sector. In England, where commissioners and providers are split, this may be through closer alliances or through the creation of Multispecialty Community Providers – as described in the NHS Five Year Forward View. Enlightened commissioners are already investing in multidisciplinary community teams providing proactive models of care expecting that this will ultimately result in cost savings across the health economy. The fact that this will improve the quality of care for patients is likely to be the greater incentive for General Practice.
The Rational Clinical Examination, Simel D and Rennie D.
The entire book is excellent, delivered in short chapters asking a specific clinical question. Thereis no separate geriatric element however many of the issues are relevant to CGA.
McLeod’s Clinical Diagnosis, Japp et al. Aimed primarily at trainee doctors. There is a short chapter on assessment of the older patient that expands on some of the themes raised here.