Comprehensive Geriatric Assessment can work for care home residents – here we give practical recommendations as to how

 The Proactive Healthcare for Older People in Care Homes (PEACH) study considered how to deliver high quality care to older people living in UK Care homes.  Here, Neil Chadborn, Claire Goodman and Adam Gordon discuss the findings of a realist synthesis on how Comprehensive Geriatric Assessment works in care homes.  This is the first of three blog posts on the subject.

Neil Chadborn is a Research Fellow in the Faculty of Medicine & Health Sciences at University of Nottingham; he tweets as @nchadborn

Background

We wrote this with care home staff and healthcare professionals in mind.  Across the UK, these professionals are trying to work more closely together to deliver care in a structured way for care home residents.  The Proactive Healthcare for Older People in Care Homes (PEACH) study tested new ways of working between NHS and care home staff to see what works best for residents.

Care homes are not hospitals but people often move into care homes with complex and ongoing health and care needs.  Doing what is best for the person needs to involve a wide range of people with different expertise and knowledge.

Care homes rely on intermittent visits from doctors, nurse specialists and therapists to support residents’ health care.  Building a multidisciplinary team requires co-operation between care home staff, who are usually employed by private or third sector companies, and workers from the National Health Service and social services. The PEACH study wanted to know if using a systematic approach to how residents’ needs were discussed, and how their care was planned, would enhance how everyone worked together to improve residents’ health.

Comprehensive Geriatric Assessment (CGA) uses information from different professionals, relatives and the older person to build a systematic understanding of a person’s health and care needs.  This is used to build a care plan which is regularly reviewed.  In hospitals, it has been successful in helping to improve older people’s health. We wanted to consider whether and how it could be used in care homes.

As part of the PEACH study, we reviewed the available evidence using an approach called realist synthesis.  We read the evidence to see if different ideas about how CGA was thought to work in care homes were supported by research and experience. We looked at 130 research studies in detail.  We found three distinctive activities, or components, that affected whether or not Comprehensive Geriatric Assessment worked in the care home setting.

Here’s some more about the first component:

Component 1 – Structured Comprehensive Assessment

In each of the examples we studied in our literature review, assessment of multiple aspects of physical and mental well-being was carried out. The aim was to make sense of the complex care needs of residents with a structured approach. Staff could then have an understanding of the various needs of residents in order to prioritise care decisions.

How comprehensive assessment was done varied in the studies we reviewed. It ranged from highly structured assessments using templates and forms, to much looser approaches based on guidance or principles.

Where highly structured assessments were used, these were completed as electronic or paper forms by a single member of staff – usually a care home nurse. Whilst this was efficient and made sure the assessment was completed, it could mean that external staff did not accept the legitimacy of the assessment.  This made it difficult to trigger decisions about future care and to involve professionals from outside the care home.

Less structured approaches allowed more flexibility and encouraged multiple professionals to assess the resident face-to-face.  This meant that healthcare professionals had a sense of ownership in the process and were more likely to act on findings.  These approaches tended not to use templates or proformas.  For this to work it needed staff to be aware of the potential for variation or inconsistencies in practice.  They also needed to have systems in place to bring together the inputs of multiple professionals who were visiting the care home at different times.

These findings lead to two recommendations for healthcare and care home staff:

  1. If highly structured templates are to be used, they should be agreed and accepted by ALL professionals, both inside and outside the home. This helps to ensure that findings will be accepted and that they can trigger the necessary responses from external agencies.
  2. With a guideline approach, encouraging multiple professionals to contribute to the assessment, planning is required about to how findings will be collated to build a comprehensive problem list over days or weeks of practitioner visits.

In our next post we’ll be discussing Component 2: Developing a Care Plan.

More about the PEACH study and see the realist synthesis in greater detail at: https://bmjopen.bmj.com/content/9/4/e026921.info

To hear more about the project, please do come to our 2019 annual lecture where Adam Gordon will be presenting the findings.