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CGA in Primary Care Settings: Introduction </div> </h1> <span property="dc:title" content="1. CGA in Primary Care Settings: Introduction" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="resource-header-details"> <div class="card-resource-type-i"> <div class="card-resource-type"> Good practice guide </div> <div class="resource-type-i-icon">i</div> <div class="resource-type-info-arrow"></div> </div> <div class="resource-type-info"><div class="resource-type-info-text">Good practices guides focus on providing information on a clinical topic.</div></div> </div> <div class="node-header-details"> <div class="card-authors-wrapper"><div class="label">Authors:</div><div class="author-details">British Geriatrics Society</div></div> <div class="card-topics-wrapper"><div class="label">Topics:</div><a href="/taxonomy/term/2935">Comprehensive Geriatric Assessment (CGA) in community settings</a>, <a href="/taxonomy/term/855">Integrated care</a></div> <div class="node-header-dates"> <div class="card-date-wrapper"><div class="label">Date Published:</div><div class="card-date"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:00:00+00:00">28 January 2019</span> </div> </div> <div class="card-date-updated"> <div class="label">Last updated: </div> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:20:00+00:00">28 January 2019</span> </div> </div> </div> <div class="card-resource-summary"> <p>An introduction to Comprehensive Geriatric Assessment (CGA) in primary care settings. This toolkit was developed by the British Geriatrics Society for professionals in primary care and has been endorsed by the Associate National Clinical Director for Older People and Integrated Person-Centred Care for NHS England and by the British Geriatrics Society Scotland Council.</p> </div> </div> <div class="view view-sections view-id-sections view-display-id-main 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76.3226359 340.119387 77.151063 340.119387L109.254879 340.119387C110.083306 340.119387 110.754879 339.447815 110.754879 338.619387 110.754879 337.79096 110.083306 337.119387 109.254879 337.119387z"/> </g> </g> </svg> </section></li> </ul></div> </div> </div> </div> <div class="views-row views-row-2 views-row-even section-row palette-default "> <div class="section-inner"> <div class="card-body"> <h2 class="sidebar-nav">What is CGA?</h2> <p>Comprehensive Geriatric Assessment (CGA) is a process of care comprising a number of steps. Initially, a multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant). Interventions are then arranged in support of the plan. Progress is reviewed and the original plan reassessed at appropriate intervals with the interventions reconsidered accordingly.</p> <p>Some bodies prefer to call it a comprehensive older age assessment (COAA). It is also referred to as geriatric evaluation management and treatment (GEMT). It is a form of integrated care and is an example of a complex intervention.</p> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-75f3a0068d87220e4b57ccb16b70276c"> </div> </div> </div> </div> <div class="views-row views-row-3 views-row-odd views-row-last section-row palette-default "> <div class="section-inner"> <div class="card-body"> <h2 class="sidebar-nav">Why is it done and who does it?</h2> <p>Evidence shows that CGA is effective in reducing mortality and improving independence (still living at home) for older people admitted to hospital as an emergency compared to those receiving usual medical care. </p> <p>In community settings, the evidence shows that complex interventions in people with frailty can reduce hospital admission and can reduce the risk of readmission in those recently discharged.</p> <p>CGA is also a vital part of the management strategy for older people suspected of having frailty in order to identify areas for improvement and support to reduce the impact of frailty. </p> <p>A recent study showed that comprehensive assessment and individualised care planning can reverse the progression of frailty.</p> <h2 class="sidebar-nav">Who does CGA?</h2> <p>The CGA process requires coordination to ensure that the experience is positive for both the patient and their families. As older people’s needs are frequently complex and always unique those coordinating the process must display advanced communication skills in addition to their clinical knowledge to ensure purposeful and timely assessment. Therefore coordination of CGA can be undertaken by any member of the health and social care team but is best carried out by someone the patient and their family trusts and with whom they can have open and sensitive discussions.  </p> <p>In many cases this will be the patient’s GP – especially if they have known the patient for some time and have been involved in other aspects of their care. GP’s in particular will be well placed to handle a medication review in the context of the overall person-centred goals. Although this could be delegated to a pharmacist, it will not be valuable unless performed as part of CGA. </p> <p>Nurses are well placed to manage the complexity of assessment in an efficient way drawing together the different strands to coordinate a personalised treatment plan in which the patient and their family share their aspirations and choices. Nurses have a duty to act as patient advocate, empowering people to make shared decisions; these roles are set out within their standards of conduct, performance and ethics.</p> <p>In cases where there is particular complexity, or where there are concerns about underlying diagnosis or treatment options, a geriatrician working in a community setting could be involved in, or even lead, CGA.</p> <h2 class="sidebar-nav">When is CGA done?</h2> <p>CGA should be considered appropriate in a number of circumstances, all of which reflect frailty in an individual (for more detailed information see Fit for Frailty Part 1 2014):</p> <ul> <li>When an older person presents to their GP with one or more obvious frailty syndromes – i.e. falls, confusion, reduced mobility and increasing incontinence even if these appear to be due to a reversible cause – such as a new medication or minor infection or if the ambulance service has already been called – it is unlikely they will have started the process of CGA.</li> <li>When a GP or community team learns of an incident which implies frailty in an individual - for example if an ambulance is called after a fall. </li> <li>When an older person has been discharged from hospital after presenting with a frailty syndrome (fall, reduced mobility, delirium etc) even if another diagnosis has been offered as the cause. Sometimes a  simplistic, and occasionally erroneous, diagnosis such as Urinary Tract Infection- UTI  appears to have caused a prolonged admission and this implies significant frailty. In this situation, the process of CGA might have been started in hospital – but it will need to be refreshed once the older person is  back in the community in a more steady state.</li> <li>In care homes - most residents of care homes (both those with and without nursing care) will have frailty. The process of CGA will help to identify the future treatment goals and support the necessary advance care planning.</li> </ul> <p>CGA should form part of the process of proactive care and would therefore be also focused on a target population - possibly those with moderate frailty identified through risk stratification. Different federations of GP’s in England will be considering their strategies for managing this approach- currently there is no well defined ‘best’ practice and there is no hard research evidence that systematic screening for frailty offers any economic benefit. Nonetheless the unplanned admissions enhanced services in primary care require consideration of risk stratification.</p> <p>Several tools for risk stratification and for frailty ‘screening’ are available and more are being developed. One new tool which may help with risk stratification is the Electronic frailty index eFI. This tool, which is now available in both TPP system one and EMIS web, uses Read codes embedded within the records to compute a score for an individual (it therefore has the obvious disadvantage of relying on good  coding).  Local decisions can be made as to the cut-off points within this range for mild, moderate and severe frailty. Likewise local plans will be needed as to the pathways to follow once an individual’s scores are available.  There are other examples of clinicians using their knowledge of their own practice population to highlight people who need more detailed assessment.</p> <h2 class="sidebar-nav">Where is CGA done?</h2> <p>Since the process of CGA can be performed anywhere, either in the older person’s home, in the GP surgery or in a special clinic set up for the purpose in a leisure centre, day centre or hospital outpatient department. The exact situation is less important than the process and activity. It should form part of the care in an acute setting.</p> <p>It is also ideally suited for the process of proactive care in community settings – however the nature of community working including the geographical and availability challenges for many members of a multi-professional team means that the process will need to be adapted as outlined in ‘How is it done?’ (see next page in this Good Practice Guide series).</p> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-9d51c0a5f704f6c184b0c3346307ef9c"> </div> </div> </div> </div> </div> </div> </article> </div> <div class="content-additional"> <div id="block-webform-client-block-227" class="block block-webform"> <h2 class="resource-feedback-toggle">Feedback on this resource?</h2> <div class="content"> <div id="webform-ajax-wrapper-227"><form class="webform-client-form webform-client-form-227" 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class="view-content view-content-main"> <div> <div class="views-field views-field-nothing"> <span class="field-content"><a class="attachment-link download-resource" target="_blank" href="https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-03-12/CGA%20Toolkit%20for%20Primary%20Care%20Practitioners_0.pdf"> <div class="file-icon file-type-pdf"><div class="file-name">CGA Toolkit for Primary Care Practitioners.pdf</div><div class="file-details"><div class="file-extension">pdf</div><div class="file-size">814.5 KB</div></div></div> </a></span> </div> </div> </div> </div></span> </div> </div> </div> </div> </div> </section> <section class="block block-views"> <div class="view view-sections view-id-sections view-display-id-sidebar view-dom-id-9349e1b07018f9316ac52a8b6a026a7d"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first side-row "> <div class="section-inner"> <div class="card-title"> <h2 class="field-content">Section 1: CGA in Primary Care</h2> </div> <div class="side-row-wrapper"> <div class="card-body"> <p><strong>Introduction (you are here)</strong><br /> <a href="/resources/2-cga-in-primary-care-settings-the-elements-of-the-cga-process">The elements of CGA</a>:<br /> - <a href="/resources/3-cga-in-primary-care-settings-physical-assessment">Physical assessment</a><br /> - <a href="/resources/4-cga-in-primary-care-settings-functional-and-social-assessment">Functional, social and environmental assessment</a><br /> - <a href="/resources/5-cga-in-primary-care-settings-psychological-components">Psychological components</a><br /> - <a href="/resources/6-cga-in-primary-care-settings-medication-review">Medication review</a><br /> - <a href="/resources/7-cga-in-primary-care-settings-creating-a-problem-list">Creating a problem list</a><br /> <a href="/resources/8-cga-in-primary-care-settings-care-and-support-planning">Care and support planning</a><br /> <a href="/resources/9-cga-in-primary-care-settings-involving-social-services">Involving Social Services</a></p> </div> </div> </div> </div> <div class="views-row views-row-2 views-row-even views-row-last side-row "> <div class="section-inner"> <div class="card-title"> <h2 class="field-content">Section 2: Specific Presentations</h2> </div> <div class="side-row-wrapper"> <div class="card-body"> <p><a href="/resources/10-cga-in-primary-care-settings-patients-presenting-with-mobility-and-balance-issues">Mobility and balance</a><br /> <a href="/resources/11-cga-in-primary-care-settings-bone-health">Bone health</a><br /> <a href="/resources/12-cga-in-primary-care-settings-patients-at-risk-of-falls-and-fractures">Falls</a><br /> <a href="/resources/13-cga-in-primary-care-settings-patients-presenting-with-depression">Depression</a><br /> <a href="/resources/14-cga-in-primary-care-settings-patients-presenting-with-confusion-and-delirium">Confusion/delirium</a><br /> <a href="/resources/15-cga-in-primary-care-settings-mental-capacity-issues">Mental capacity</a><br /> <a href="/resources/16-cga-in-primary-care-settings-patients-presenting-with-urinary-incontinence">Urinary incontinence</a><br /> <a href="/resources/17-cga-in-primary-care-settings-weight-loss-and-nutrition-issues">Weight loss and nutrition</a><br /> <a href="/resources/18-cga-in-primary-care-settings-end-of-life-care-issues">End of life care</a></p> </div> </div> </div> </div> </div> </div> </section> </div> </aside> </div> </main> <section class="postscript-first"> <div class="postscript_first"> <section class="block block-views postscript-section-row-block"> <h2 class="block-title">Other resources in this series</h2> <div class="view view-resource-series view-id-resource_series view-display-id-block section-row row-max-4 view-card-default-palette view-dom-id-824ea7d5ec666c8af9f65b62e4233c57"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first"> <a class="card resource-card" href="/resources/2-cga-in-primary-care-settings-the-elements-of-the-cga-process"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>2. CGA in Primary Care Settings: The elements of the CGA process</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:00:00+00:00">28 Jan 2019</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> An overview of how Comprehensive Geriatric Assessment (CGA) is done in the primary care setting, and what to consider when conducting the assessment. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Good practice guide </div> </div></div></a> </div> <div class="views-row views-row-2 views-row-even"> <a class="card resource-card" href="/resources/3-cga-in-primary-care-settings-physical-assessment"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>3. CGA in Primary Care Settings: Physical Assessment </h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:00:00+00:00">28 Jan 2019</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> Examination of older patients incorporates all the typical aspects of clinical examination, although there are some general considerations and emphases that should be borne in mind, and specific examinations that may be more relevant in older people. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Good practice guide </div> </div></div></a> </div> <div class="views-row views-row-3 views-row-odd"> <a class="card resource-card" href="/resources/4-cga-in-primary-care-settings-functional-and-social-assessment"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>4. CGA in Primary Care Settings: Functional and social assessment</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:00:00+00:00">28 Jan 2019</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> Functional assessment examines factors like mobility and daily living activities, and social assessment looks at social circumstances. Asking what the older person does and what environment they live in adds context to any Comprehensive Geriatric Assessment. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Good practice guide </div> </div></div></a> </div> <div class="views-row views-row-4 views-row-even views-row-last"> <a class="card resource-card" href="/resources/5-cga-in-primary-care-settings-psychological-components"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>5. CGA in Primary Care Settings: Psychological components</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2019-01-28T00:00:00+00:00">28 Jan 2019</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> Depression among the over-65s is often under-recognised, so CGA is not complete without assessing mental health. The assessment conversation also offers an opportunity to identify cognitive dysfunction which may be a sign of dementia or delirium. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Good practice guide </div> </div></div></a> </div> </div> <div class="view-footer"> <div class="card-feed-link"><a href="/resources/resource-series/comprehensive-geriatric-assessment-toolkit-for-primary-care-practitioners">See all resources in this series</a></div> </div> </div> </section> </div> </section> <footer id="site-footer" role="contentinfo"> <section class="footer-first"> <div class="outer-wrapper"> <section class="block block-views"> <div class="view view-footer-sections view-id-footer_sections view-display-id-orgs view-display-grid view-dom-id-3f47594b71a7da42fc385f85ac558e68"> <div class="view-header"> <script> if(jQuery('#Main.CRM_Contribute_Form_Contribution_Main').length > 0){ jQuery('#Main.CRM_Contribute_Form_Contribution_Main').on('submit',function(e){ setTimeout(function(){ e.preventDefault(); 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