The Proactive Ageing Well Service: Delivering Home-Based CGA Through an Integrated Neighbourhood Model

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L Scarlett1; K Tun1; E Fender1 ; J Scholes 1; M Murphy1; J Gerard 3; S Mbale1; C Furness5; K Asavisanu1; B Johnstone1; L Kitchen1; S Lightbody1; A Gowland1; S Sikder1; E Alduaij1; E Alarik1; N Alanazi1; R Alhoqail1; A Ollerton5; S Siva5; L Robinson1; R D

1 Department of Ageing and Health, Guys and St Thomas’ NHS Foundation Trust, London, ; 2 CARICE, Faculty of Life Sciences & Medicine, King’s College London, London, UK; 3 Age UK Lambeth, London; 4 East Street Surgery, Southwark, London; 5 Quay Health Solu

Clinical Quality Research

CQ - Improved Access to Service

CGA in community settings

View DOI

Abstract

Introduction
- Frailty is associated with functional decline, multimorbidity and increased emergency healthcare use. Comprehensive Geriatric Assessment (CGA) is the gold standard for frailty management but remains difficult to access for many housebound older adults. Proactive Ageing Well Service (PAWS) are being established across Southeast London (SEL). This service evaluation reports the population assessed, interventions delivered and healthcare utilisation of those receiving specialist multidisciplinary CGA at home through an integrated neighbourhood model in 2 of the SEL boroughs, Lambeth and Southwark.
Methods
- A service evaluation of patients receiving domiciliary CGA between November 2024 and March 2026. Data collected included demographics, Clinical Frailty Scale (CFS), CGA interventions (medical optimisation, medicines management, rehabilitation, cognition, continence, sensory health, social support and advance care planning) and unplanned attendances at one local acute trust.
Results
- 227 residents received domiciliary CGA; complete data were available for 184. Median age was 81.8 years and 56% had moderate-to-severe frailty (CFS ≥6). Interventions included medication optimisation (71.7%), optimisation of long-term conditions (55.4%), support accessing community services (55.4%), occupational therapy referral (11.4%), diagnostic cognitive assessment (10.9%), continence advice (15.8%), referrals for podiatry (12.5%), vision (10.9%) and hearing (12.5%), and new advance care plans (52%). Mean emergency department attendances fell from 1.83 to 1.38 per patient, with 52% experiencing fewer attendances. Mean hospital admissions decreased from 4.63 to 3.29 per patient, with 46% experiencing fewer admissions.
Conclusion
- PAWS successfully delivered multidisciplinary CGA to a complex housebound population, identifying substantial unmet need across multiple CGA domains. This integrated neighbourhood model improved access to specialist frailty care and was associated with reduced unplanned hospital use, supporting its potential as a scalable approach to community-based frailty management.