A nurse-led comprehensive geriatric assessment intervention in primary care: A feasibility cluster randomized controlled trial.

AIM: To determine the feasibility of a nurse-led, primary care-based comprehensive geriatric assessment (CGA) intervention. DESIGN: A feasibility cluster randomized controlled trial. METHODS: The trial was conducted in six general practices in the United Kingdom from May 2018 to April 2020. Participants were moderately/severely frail people aged 65 years and older living at home. Clusters were randomly assigned to the intervention arm control arms. A CGA was delivered to the intervention participants, with control participants receiving usual care. Study outcomes related to feasibility of the intervention and of conducting the trial including recruitment and retention. A range of outcome measures of quality of life, function, loneliness, self-determination, mortality, hospital admission/readmission and number of prescribed medications were evaluated. RESULTS: All pre-specified feasibility criteria relating to recruitment and retention were met with 56 participants recruited in total (30 intervention and 26 control). Retention was high with 94.6% of participants completing 13-week follow-up and 87.5% (n = 49) completing 26-week follow-up. All outcome measures instruments met feasibility criteria relating to completeness and responsiveness over time. Quality of life was recommended as the primary outcome for a definitive trial with numbers of prescribed medications as a secondary outcome measure. CONCLUSION: It is feasible to implement and conduct a randomized controlled trial of a nurse-led, primary care-based CGA intervention. IMPACT: The study provided evidence on the feasibility of a CGA intervention for older people delivered in primary care. It provides information to maximize the success of a definitive trial of the clinical effectiveness of the intervention. PATIENT OR PUBLIC CONTRIBUTION: Patient and public representatives were involved in the study design including intervention development and production of participant-facing documentation. Representatives served on the trial management and steering committees and, as part of this role, interpreted feasibility data. ISRCTN Number: 74345449.

Designing a nurse-led assessment and care planning intervention to support frail older people in primary care: An e-Delphi study.

AIM: To identify and establish expert consensus on important and feasible components of a nurse-led, comprehensive geriatric assessment (CGA)-based intervention for community-dwelling older people who live with frailty. DESIGN: A three-round modified e-Delphi survey. METHODS: An expert panel of 33 UK specialist older people's, primary and community care nurses participated in the three-round e-Delphi survey over a 12-month period in 2017-2018. Data from round 1 were analysed using content analysis. Descriptive statistics were used in the subsequent two rounds to demonstrate convergence of panel opinion and consensus. RESULTS: In round 1, experts proposed 30 CGA components that were combined with six additional components from a literature review and clustered into six domains. In round 2, components were rated for importance and feasibility. Rating scores for importance were high across all domains, with lower scores for feasibility. Round 3 revealed that 36 components achieved consensus on importance and 11 out of 36 components reached consensus on feasibility. CONCLUSION: Based on expert panel opinion, the content of a nurse-led CGA-based intervention was established, with the aim of future feasibility testing in a randomized controlled trial. IMPACT: This study provides feasible components of a CGA-based intervention that can be implemented in clinical practice by nurses in partnership with older people who live with frailty. Following further testing and evaluation, the components have the potential to improve clinical outcomes, maximize independence and improve the quality of life for community-dwelling frail older people.

The holistic assessment and care planning in partnership intervention study (HAPPI): A protocol for a feasibility, cluster randomized controlled trial.

AIM: During an initial phase of this research, an e-Delphi survey was conducted to gain consensus among stakeholders on the components of a nurse-led assessment and care planning intervention for older people who live with frailty in primary care. This feasibility randomized controlled trial (fRCT) will test the proposed intervention and its implementation and determine methods for the design of a conclusive randomized controlled trial. METHODS: The fRCT, with embedded qualitative study, aims to recruit 60 participants. Moderately and severely frail older people will be identified using the electronic frailty index (eFI) and the intervention will be delivered by senior community nurses. The control participants will receive usual primary care for frailty. The study is funded by the National Institute of Health Research (NIHR; funding granted in May 2016, ref: ICA-CDRF-2016-02-018) and received NHS and University Research Ethics Committee approval in 2018. DISCUSSION: There is evidence that the delivery of complex interventions for community-dwelling older people can reduce care home and hospital admissions and falls, there is less evidence for the benefit of any specific type or intensity of intervention or the additional benefits of targeting the frail population. This trial will determine feasibility of the intervention, define recruitment and retention parameters and trial logistics, and decide outcome measures. IMPACT: This study aims to address the limitations of current research by using a systematic method of frailty diagnosis and participant identification, trialling implementation of a person-centred intervention, and testing of feasibility parameters. TRIAL REGISTRATION NUMBER: ISRCTN: 74345449.

Standard set of health outcome measures for older persons.

BACKGROUND: The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons. The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services. METHODS: A modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group. RESULTS: The outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework. CONCLUSIONS: The first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.

Reframing frailty as a long-term condition.

Frailty is a clinical syndrome that focuses on loss of reserve, energy and wellbeing. Older people with frailty tend to present late and often in crisis to health and care services so their care may be hospital-based, episodic and unplanned. Frailty should be reframed as a long-term condition that can be managed proactively in primary and community settings by supported self-management and person-centred care. Nurses play a vital role as key workers, care co-ordinators and supporters to patients and their carers at all stages of the frailty trajectory.

How can we improve Comprehensive Geriatric Assessment for older people living with frailty in primary care and community settings? A qualitative study.

OBJECTIVE: With advancing age comes the increasing prevalence of frailty and increased risk of adverse outcomes (eg, hospitalisation). Evidence for comprehensive geriatric assessment (CGA), a multidimensional holistic model of care, is mixed in community settings. Uncertainties remain, such as the key components of CGA, who delivers it, and the use of technology. This study aimed to understand the perspectives, beliefs and experiences, of both older people and health professionals, to improve the current CGA and explore factors that may impact on CGA delivery in community settings. DESIGN: A qualitative interview study was conducted with older people and healthcare professionals (HCPs) identified using a maximum variation strategy. Data were analysed using an abductive analysis approach. The non-adoption, abandonment, scale-up, spread and sustainability framework and the theoretical framework of acceptability guided the categorisation of the codes and identified categories were mapped to the two frameworks. SETTING: England, UK. RESULTS: 27 people were interviewed, constituting 14 older people and 13 HCPs. We identified limitations in the current CGA: a lack of information sharing between different HCPs who deliver CGA; poor communication between older people and their HCPs and a lack of follow-up as part of CGA. When we discussed the potential for CGA to use technology, HCPs and older people varied in their readiness to engage with it. CONCLUSIONS: Viable solutions to address gaps in the current delivery of CGA include the provision of training and support to use digital technology and a designated comprehensive care coordinator. The next stage of this research will use these findings, existing evidence and stakeholder engagement, to develop and refine a model of community-based CGA that can be assessed for feasibility and acceptability.

Equipping the healthcare workforce to meet the complex health needs of older people in the community: a skills-led approach.

The shift towards delivering more clinical care in the community not only supports the healthcare system by avoiding unnecessary hospital admissions, but can also improve outcomes, particularly for older people with complex healthcare needs. Therefore, healthcare organisations need to consider how to ensure their workforce has the capabilities required to provide care in accordance with this new model. This article details a project that involved the design and development of a replicable Ageing Well programme of learning to increase knowledge, skills and confidence among registered and unregistered practitioners, underpinned by a 'skills not roles' strategy. Although evaluation of the programme is ongoing, the authors encourage its wider adoption by outlining its benefits, how the challenges encountered during this project were overcome and the learning points gained from the experience.

Telehealth enhances self care and independence in people with long term conditions.

The increasing prevalence of long term conditions will influence all nurses' practice, irrespective of their particular field. NHS Cornwall is taking part in a government trial, known as the whole system demonstrator programme, piloting telehealth and telecare to manage long term conditions. This article reports the initial positive results.

Effectiveness of nurse-coordinated, person-centered comprehensive assessment on improving quality of life of community-dwelling, frail older people: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to determine the effectiveness of nurse-coordinated, person-centered comprehensive assessment on improving quality of life of community-dwelling, frail older people. INTRODUCTION: There is a growing need to meet the challenges of the increasingly frail and older population, and to provide proactive, holistic care close to home. A standardized assessment and care planning intervention could be implemented in primary care, which could be delivered by a primary or community healthcare nurse to address these challenges. However, it is not yet clear if an assessment and care planning intervention will improve outcomes for patients, such as quality of life. INCLUSION CRITERIA: This review will consider studies that evaluate nurse-coordinated, person-centered, comprehensive assessment delivered in partnership with community-dwelling, frail older people, and will compare the intervention to usual care. Studies that include people aged 60 years and older living at home or in supported living accommodation with a recognized level of frailty as assessed by use of frailty screening or assessment tools, will be considered. Studies that include outcomes of health-related quality of life, social functioning, and well-being will also be considered. METHODS: An initial limited search of PubMed and CINAHL has been undertaken to identify articles on the topic. The following sources will be searched for eligible papers: PubMED, CINAHL, Embase, PsycINFO, BNI, AMED, and OpenGrey. Retrieval of full-text studies, assessment of methodological quality, and data extraction will be performed independently by two reviewers. Meta-analysis will be performed, if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019137886.