The Geriatric Outreach and Liaison Service for Coventry Care Homes (GOALS Cov Service)

Introduction 

The GOALS-Cov service was developed by a joint primary and secondary care working group seeking to reduce avoidable hospital admissions among older adults living with frailty. Analysis showed that a small number of care homes accounted for a disproportionate share of readmissions, identifying them as priority for intervention.

Method 

After selecting these homes, stakeholders co‑designed a service tailored to residents’ needs. Contributors included GPs, care home managers, community nurses, physiotherapists and elderly‑care specialists. Together they shaped a model in which a care‑of‑the‑elderly multidisciplinary team (MDT) would join a weekly MDT meeting and provide personalised follow‑up visits to residents.

Pilot MDT meetings were held before launch to test the model. Feedback led to refinements, including revised meeting times and clearer handover process. 

The six‑month pilot then began, supported by structured feedback from all involved. Monthly analysis of hospital attendances and deaths enabled rapid, person‑centred adjustments throughout.

Results 

End‑of‑life outcomes: Strengthened advance care planning increased the proportion of residents able to die in their preferred place of care. 

Hospital activity: Hospital use fell substantially during the pilot. 

Healthcare professional feedback: Staff reported improved communication and stronger support for care home teams, who felt more confident advocating for residents. 

Resident and family feedback: Satisfaction was unanimously positive, with 100% reporting good communication and overall experience. Reported benefits included better symptom management, clearer advance care planning, fewer hospital admissions, and improved coordination. 

Additional benefits: 

• 33% of residents had one or more medications safely deprescribed. 

• Unnecessary outpatient appointments and investigations were reduced. 

• 80% of care workers reported increased frailty knowledge. 

• Stronger primary–secondary care relationships supported ongoing collaboration.

Conclusion 

The service delivered higher patient satisfaction, fewer unplanned admissions, more complete advance care plans, and improved end‑of‑life outcomes. As the model has matured, MDT frequency has been adjusted to create capacity for further expansion.