The Proactive Ageing Well Service: Delivering Comprehensive Geriatric Assessment Beyond the Hospital to Identify Hidden Frailty
Abstract
Abstract Author Name : K Tun1; L Scarlett1; E Fender2; M Murphy1; J Gerrard3; S Mbale2; M Gardener2; K Asavisanu1; L Kitchen1; S Lightbody1; S Sikder1 ; A Gowland1; J Scholes2; E Alduaij1; E Alaraik1; N Alanazi1; R Alhoqail1,8; A Bevan7; S Siva4; J Whitney5; R Dallmeyer4; G Walker1; T Kalsi1,6
Abstract Provenance : 1Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust 2Integrated Care Transformation Team, Guy’s and St Thomas’ NHS Foundation Trust 3Age UK Lambeth 4Quay Health Solutions 5Kings College Hospital 6CARICE, Faculty of Life Sciences & Medicine, King’s College London, London, UK 7South London and Maudsley NHS Foundation Trust 8Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Background
Older adults living with frailty in deprived urban communities often experience barriers to specialist geriatric services, resulting in delayed identification of frailty and unmet needs. NHS-10-Year-Health-Plan and BGS-Joining-the-Dots strategy advocate for proactive neighbourhood-based care. The Proactive Ageing Well Service developed a multidisciplinary outreach programme delivering comprehensive geriatric assessment(CGA) within community settings(sheltered accommodations, churches, mosques) in London boroughs of Lambeth and Southwark. We evaluate the characteristics, unmet needs, interventions delivered and outcomes.
Methods
Prospective service evaluation across 18 outreach events(November/2024–January/2026). Multidisciplinary team(MDT) comprising consultant geriatrician, specialty registrar, frailty practitioner, social prescriber and other guest MDT members(physiotherapists/occupational therapists) delivered structured CGA addressing What Matters, multi-morbidity, medicines optimisation, function, cognition, sensory health, continence, social well-being and advance care planning. Routinely collected data were analysed descriptively.
Results
Total 141 residents attended. Mean age 73.7 years, 59.3%were female and 53.4%had mild-severe frailty. Most(77.7%) lived within the most deprived Index of Multiple Deprivation deciles(1–3), 47.9% identified as Black/Black British and had 6.6 mean long-term conditions. CGA identified extensive unmet needs including sensory impairment, functional dependency and multi-morbidity. Participants received mean 5.56 interventions each: symptom management(66%), medication and/or comorbidity optimisation(54.6%), falls/bone health interventions(54.6%), bladder/bowel management(50%), social prescribing(36.2%), occupational therapy interventions(19.1%), and sensory referrals(15.6%). Follow-up evaluation demonstrated a statistically significant reduction in mean emergency department attendances from 1.55 to 0.91 per participant, with 64%experiencing fewer attendances(Wilcoxon signed-rank p=0.032). Mean hospital admissions also reduced from 1.11 to 0.68 per participant, with 58%experiencing fewer admissions(trend towards significance Wilcoxon p=0.071).
Conclusion
Outreach CGA programme identified substantial unmet multidimensional needs in ethnically diverse, deprived older adults who may not otherwise access specialist services. Delivering CGA within trusted community settings enabled proactive identification of frailty and reduced emergency services utilisation/hospitalisations. Integrated neighbourhood model provides a scalable approach to reducing health inequalities and improving equitable access to specialist frailty care.