Access to Comprehensive Geriatric Assessment in the Community

What was the issue you were addressing or working on?

Anticipating patients that are moving towards a health transition because of emerging health issues.

In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.


What you did?

Appointed a Nurse Practitioner to work with Consultant Geriatrician.  The Post was funded by the Change Fund. The Nurse works in partnership with the acute hospital A&E department.  The Nurse makes contact with all patients who are 65yrs who presented to A&E and were subsequently discharged to ascertain if the commencement of a Comprehensive Geriatric Assessment would be appropriate.  If appropriate the Nurse Practitioner visits the patient in their home and begins the assessment.  If the patient has complex issues then the patient is booked into the Consultant Geriatrician clinic at the nearest Community Hospital or in the acute outpatient department.  If the patient is unable to attend an appointment the Consultant will carry out a house call.


What were the outcomes - benefits or otherwise?

Moray’s admission rates, bed days and readmission rates are dropping.  Case studies from the Nurse Practitioner suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.

The project has now branched out to take referrals from GP’s (particularly supporting medicines reconciliation) and District Nurses (complex long term conditions).  The Nurse Practitioner is also taking referrals from the Acute Medical Assessment Unit and the acute medical ward if patients are discharged but would benefit from a Comprehensive Geriatric Assessment.


Contacts - to find out more

Alison Smart, Alison.smart@nhs.net   07557317800